Moral injury among women military veterans and demand for cigarettes: A behavioral economic investigation using a hypothetical purchase task.

OBJECTIVES: Unlike the United States general population, veteran women - as opposed to veteran men - have greater smoking prevalence; yet, little is known regarding factors that influence smoking in veteran women. The purpose of this study was to begin examining the relationship between a psychological concept known as moral injury and demand for cigarettes among veteran women. METHODS: Veteran women who smoke (n = 44) were recruited for this cross-sectional study from Amazon MTurk, Reddit, and a veteran-serving non-profit organization in June-July 2023. Consenting participants received $2 for completing the cigarette purchase task (CPT), Fagerstrom Test for Nicotine Dependence (FTND), and the military version of the Moral Injury Symptom Scale (MISS-M-SF). We examined five CPT demand indices and calculated a modified exponential demand model stratified by moral injury severity status (i.e., probable vs. unlikely). RESULTS: Probable morally injured women exhibited significantly higher relative reinforcing value (RRV) for smoking than unlikely morally injured women (F1, 920 = 9.16, p = 0.003). Average cigarette consumption at $0 (i.e., Q0) was 48.56% higher (M = 22.24 vs. M = 13.55) in probable compared to unlikely morally injured women (p = 0.04, Hedge's g = 0.74). FTND scores were significantly correlated with Pmax (i.e., demand elasticity point) and Omax (i.e., maximum expenditure) values in both populations (rs = 0.42-0.68, ps < 0.05). CONCLUSIONS: We provide preliminary evidence of the relatively high RRV of smoking in morally injured veteran women. Continued research is needed to refine the characterization of this relationship.

Sex differences in tobacco use, attempts to quit smoking, and cessation among dual users of cigarettes and e-cigarettes: Longitudinal findings from the US Population Assessment of Tobacco and Health Study.

SIGNIFICANCE: A growing number of adults use more than one tobacco product, with dual use of cigarettes and e-cigarettes being the most common combination. Monitoring sex disparities in tobacco use is a public health priority. However, little is known regarding whether dual users differ by sex. METHODS: Data came from Waves 4-6 (12/2016-11/2021) of the Population Assessment of Tobacco and Health Study, a US nationally-representative longitudinal survey. This analysis included current adult dual users of cigarettes and e-cigarettes. We used weighted generalized estimating equations to assess the association between sex and (1) making a cigarette quit attempt (n = 1882 observations from n = 1526 individuals) and (2) smoking cessation (n = 2081 observations from n = 1688 individuals) across two wave pairs, adjusting for age, education, ethnicity, time-to-first cigarette after waking, and e-cigarette use frequency. RESULTS: Among US dual users, 14.1% (95% Confidence Intervals [Cl] = 11.9-16.4) of females and 23.4% (20.0-26.9) of males were young adults (aged 18-24), 11.7% (9.2-14.2) of females and 14.4% (11.6-17.2) of males had

Examining U.S. disparities in smoking among rural versus urban women of reproductive age: 2002-2019.

OBJECTIVE: This study is part of a programmatic investigation of rural disparities in cigarette smoking examining disparities in smoking prevalence and for the first-time quit ratios among adult women of reproductive age (18-44 years), a highly vulnerable population due to risk for multigenerational adverse effects. METHODS: Data came from 18 years (2002-2019) of the U.S. National Survey on Drug Use and Health (NSDUH) among women (n = 280,626) categorized by rural-urban residence, pregnancy status, using weighted logistic regression models testing time trends and controlling for well-established sociodemographic predictors of smoking (race/ethnicity, education, income). Concerns regarding changes in survey methods used before 2002 and after 2019 precluded inclusion of earlier and more recent survey years in the present study. RESULTS: Overall smoking prevalence across years was greater in rural than urban residents (adjusted odds ratio [AOR] = 1.11; 95%CI, 1.07-1.15; P < .001) including those not-pregnant (AOR = 1.10; 1.07-1.14; P < .001) and pregnant (AOR = 1.29; 1.09-1.52; P < .001). Overall quit ratios across years were lower in rural than urban residents (AOR = 0.93; 0.87-0.99; P < .001) including those not-pregnant (AOR = 0.93; 0.88-1.00, P = .035) and pregnant (AOR = 0.78; 0.62-0.99; P = .039). Interactions of rural versus urban residence with study years for prevalence and quit ratios overall and by pregnancy status are detailed in the main text. CONCLUSIONS: These results support a longstanding and robust rural disparity in smoking prevalence among women of reproductive age including those currently pregnant and provides novel evidence that differences in smoking cessation contribute to this disparity further underscoring a need for greater access to evidence-based tobacco control and regulatory interventions in rural regions.

Cigarette smoking and cognitive task performance: Experimental effects of very-low nicotine-content cigarettes.

Reductions in the nicotine content of cigarettes decrease smoking rate and dependence severity, but effects on cognition are less well established. The potential impacts of very-low nicotine-content (VLNC) cigarettes on cognitive task performance must be evaluated, especially in vulnerable populations. The aim of the present study is to experimentally examine the effects of VLNC cigarettes on cognitive performance. Adults who smoked daily (n = 775) from three vulnerable populations (socioeconomically disadvantaged reproductive-age women, individuals with opioid use disorder, affective disorders) were examined. Participants were randomly assigned to normal nicotine content (NNC; 15.8 mg nicotine/g tobacco) or VLNC (2.4 mg/g or 0.4 mg/g) cigarettes for 12 weeks. Response inhibition (stop-signal task), working memory (n-back task; n of 2-n of 0), and cognitive interference (nicotine Stroop task) were assessed at baseline, 2, 6, and 12 weeks. Results were analyzed using mixed-model repeated-measures analyses of variance. Extended exposure to VLNC cigarettes produced no significant changes in any measure of cognitive performance compared to NNC cigarettes. Over weeks, response times on the n-back task decreased across doses. No significant effects were observed on the stop-signal or nicotine Stroop tasks. All three vulnerable populations performed comparably on all three cognitive tasks. Extended exposure to VLNC cigarettes produced no impairments in cognitive performance on any of the assessed tasks compared to NNC cigarettes. These findings are consistent with the larger literature detailing other consequences following exposure to VLNC cigarettes and are encouraging for the adoption of a nicotine-reduction policy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Electronic nicotine delivery systems (ENDS): Frequency of use and smoking-cessation efforts among U.S. women of reproductive age.

OBJECTIVE: Reducing harm from combustible cigarette use among women of reproductive age (WRA) is critical given their potential vulnerability to multigenerational adverse impacts of cigarette smoking. Although electronic nicotine delivery systems (ENDS) are not approved smoking cessation aids in the US, many WRA who smoke report using ENDS to help quit smoking. Associations between ENDS use patterns and smoking-cessation efforts among US WRA remain unclear. METHODS: Using the Population Assessment of Tobacco and Health (PATH) Study, we examined whether baseline (Wave 3 or 4) ENDS use frequency predicted (a) making a cigarette quit attempt (QA) and (b) successful quitting by follow-up (Wave 4 or 5, respectively) among WRA (N = 2834; 72.1% non-Hispanic White). RESULTS: Daily ENDS use predicted greater adjusted odds of making a QA than non-daily (AOR = 1.63, 95% CI = 1.03, 2.59) and no ENDS use (AOR = 1.97, 95% CI = 1.23, 3.14), and greater odds of successful smoking cessation than non-daily use (AOR = 2.37, 95% CI = 1.31, 4.26). Daily ENDS use did not significantly improve odds of successful smoking cessation compared to no ENDS use (AOR = 1.62, 95% CI = 0.97, 2.69). Non-daily ENDS use did not significantly improve odds of making a QA (AOR = 1.21, 95% CI = 0.94, 1.56) and hindered successful smoking cessation compared to no ENDS use (AOR = 0.68, 95% CI = 0.48, 0.98). CONCLUSIONS: These findings suggest that benefits of ENDS for smoking cessation in WRA may be greatest among those who use ENDS daily. WRA who choose to use ENDS to help quit would be well-informed by evidence that non-daily ENDS use may impede smoking cessation.

Changes in weight among individuals with psychiatric conditions or socioeconomic disadvantage assigned to smoke very low nicotine content cigarettes.

Nicotine abstinence leads to weight gain, which could be an unintended consequence of a nicotine reduction policy. This secondary analysis used weekly assessments of weight and ratings of "increased appetite/hunger/weight gain" collected in three 12-week, randomized controlled trials evaluating the effects of cigarettes differing in nicotine dose (15.8, 2.4, or 0.4 mg/g) among individuals with affective disorders, opioid use disorder (OUD), and socioeconomically disadvantaged women. Linear mixed models tested differences by dose and time. Analyses first collapsed across populations and then separated out individuals with OUD because biomarkers suggested they used substantially more noncombusted nicotine. Across populations, weight increased significantly over time, averaging 1.03 kg (p < .001), but did not vary by dose nor was there any interaction of dose/time. "Increased appetite/hunger/weight gain" ratings increased significantly as a function of dose, with differences between low and high doses (1.95 and 1.73, respectively, p = .01), but not by time nor any interaction. In the combined group of individuals with affective disorders and socioeconomically disadvantaged women, weight and "increased appetite/hunger/weight gain" ratings increased significantly by dose, with differences between low and high doses (1.43 vs. 0.73 kg, p = .003 and 2.00 vs. 1.76, p = .02, respectively). Among individuals with OUD, there were no significant effects of any kind on either outcome. Individuals with affective disorders and socioeconomically disadvantaged women gained weight and reported more subjective appetite/weight gain when given 0.4, but not 2.4 mg/g cigarettes, despite comparable decreases in nicotine exposure. However, neither change was clinically significant, suggesting minimal short-term adverse consequences of a nicotine reduction policy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Loss aversion predicts cigarette smoking status across levels of sociodemographic characteristics.

Loss aversion (LA) is a tendency to be more sensitive to potential losses relative to similar gains. Low LA is associated with increased risk for cigarette smoking and use of other substances. Previous studies of LA and smoking risk controlled for potentially confounding influences of sociodemographic characteristics associated with smoking risk. The present study replicates these earlier observations while also examining the generality of the association between low LA and smoking risk within different levels of each of the five sociodemographic risk factors for smoking (age, educational attainment, gender, income, race/ethnicity). Parallel analyses were conducted using delay discounting (DD) as a positive control; DD is a decision-making bias regarding the rate at which rewards lose value with increasing delay to receipt. Participants were recruited using standard crowdsourcing methods and completed a sociodemographics questionnaire, a hypothetical gamble task measure of LA, and a monetary choice measure of DD. Low LA was associated with increased risk of cigarette smoking after accounting for the influence of sociodemographic characteristics and DD. Similarly, high DD was associated with increased risk of cigarette smoking after accounting for the influence of sociodemographic characteristics and LA. Further analyses showed that associations of LA with smoking risk or DD with smoking risk generally although not always remained significant within varying levels of the sociodemographic characteristics of interest. These results provide support for low LA as a reliable risk factor for smoking that has generality within and across sociodemographic characteristics and closely parallels associations observed with DD and smoking risk. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Behavior change, health, and health disparities 2023: Contingency management for treating substance use disorders and promoting health in vulnerable populations.

This Special Issue (SI) of Preventive Medicine is the 10th in a series on behavior change, health, and health disparities. This issue focuses on Contingency Management (CM), a highly efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change. Despite substantial support for its efficacy, CM remains largely unavailable in U.S. community SUD treatment facilities and other healthcare settings. This is especially concerning regarding stimulant use disorder for which CM is the only reliably efficacious intervention in controlled studies and yet is unavailable to the vast majority of those in need. This SI details recent promising developments in efforts to surmount longstanding implementation obstacles while also detailing other promising advances from meta-analyses and controlled trials examining CM's efficacy in treating other difficult-to-treat problems including smoking among pregnant women and mothers of young children as well among those as those experiencing homelessness and alcohol use disorder, the promise of digital CM, and a potential new application in promoting adherence with SUD medications.

Randomized clinical trial examining financial incentives for smoking cessation among mothers of young children and possible impacts on child secondhand smoke exposure.

This randomized clinical trial examined whether financial-incentives increase smoking cessation among mothers of young children and potential impacts on child secondhand-smoke exposure (SHSe). 198 women-child dyads were enrolled and assigned to one of three treatment conditions: best practices (BP, N = 68), best practices plus financial incentives (BP + FI, N = 63), or best practices, financial incentives, and nicotine replacement therapy (BP + FI + NRT, N = 67). The trial was completed in Vermont, USA between June 2015 and October 2020. BP entailed staff referral to the state tobacco quitline; financial incentives entailed mothers earning vouchers exchangeable for retail items for 12 weeks contingent on biochemically-verified smoking abstinence; NRT involved mothers receiving 10 weeks of free transdermal nicotine and nicotine lozenges/gum. Baseline, 6-, 12-, 24-, and 48-week assessments were conducted. Primary outcomes were maternal 7-day point-prevalence abstinence and child SHSe through the 24-week assessment with the 48-week assessment exploratory. Results were analyzed using mixed model repeated measures for categorical data. Odds of maternal abstinence were greater among mothers in BP + FI and BP + FI + NRT compared to BP at the 6- and 12-week assessments (ORs ≥ 7.30; 95% CIs: 2.35-22.71); only abstinence in BP + FI remained greater than BP at the 24-week assessment (OR = 2.95; 95% CIs: 1.06-8.25). Abstinence did not differ significantly between treatment conditions at the 48-week assesssment. There was a significant effect of treatment condition (F[2109] = 3.64, P = .029) on SHSe with levels in BP and BP + FI significantly below BP + FI + NRT (ts[109] ≥ -2.30, Ps ≤ 0.023). Financial incentives for smoking abstinence are efficacious for increasing maternal cessation but that alone was insufficient for reducing child SHSe. ClinicalTrials.gov:NCT05740098.

Contingency management interventions for abstinence from cigarette smoking in pregnancy and postpartum: A systematic review and meta-analysis.

Contingency management is one of the most effective treatments for substance use disorders in not-pregnant people. The most recent quantitative review of its efficacy among pregnant and postpartum women who smoke cigarettes concluded with moderate certainty that those receiving contingent financial incentives were twice as likely to be abstinent compared with controls. We aimed to update and extend previous reviews. Five databases were systematically searched for randomized controlled trials (RCTs) published before December 2022 that assessed the effectiveness of incentives for abstinence from substance use. Data from trials of smoking abstinence were pooled using a random-effects meta-analysis model (restricted maximum likelihood). Results are reported as risk-ratios (RRs) with 95% confidence intervals (CIs). This study is registered with PROSPERO, CRD42022372291. Twelve RCTs (3136) pregnant women) were included. There was high certainty evidence that women receiving incentives were more likely to be abstinent than controls at the last antepartum assessment (12 RCTs; RR = 2.43, 95% CI 2.04-2.91, n = 2941, I2 = 0.0%) and moderate certainty evidence at the longest postpartum assessment while incentives were still available (five RCTs; RR = 2.72, 1.47-5.02, n = 659, I2 = 44.5%), and at the longest postpartum follow-up after incentives were discontinued (six RCTs; RR = 1.93, 1.08-3.46, n = 1753, I2 = 51.8%). Pregnant women receiving incentives are twice as likely to achieve smoking abstinence during pregnancy suggesting this intervention should be standard care for pregnant women who smoke. The results also demonstrate that abstinence continues into the postpartum period, including after incentives are discontinued, but more trials measuring outcomes in the postpartum period are needed to strengthen this conclusion.

Extending contingency management for smoking cessation to patients with or at risk for cardiovascular disease: A preliminary trial of a home-based intervention.

Cigarette smoking puts individuals with or at risk for developing cardiovascular disease (CVD) in jeopardy of experiencing a major cardiovascular event. Contingency management (CM) for smoking cessation is an intervention wherein financial incentives are provided contingent on biochemically verified smoking abstinence. Conventional CM programs typically require frequent clinic visits for abstinence monitoring, a potential obstacle for patients with medical comorbidities who may face barriers to access. This preliminary study examined the feasibility and comparative efficacy of (a) usual care (UC; advice to quit smoking, self-help materials, quitline referral) versus (b) UC plus home-based CM for smoking cessation (UC + HBCM). HBCM entailed earning monetary-based vouchers contingent on self-reported 24-hr smoking abstinence biochemically verified by a breath carbon monoxide (CO) sample ≤ 6 ppm. Participants were 20 outpatients with a CVD diagnosis or qualifying CVD risk factor randomly assigned 1:1 to the two conditions. Intervention participants received 14 in-home abstinence visits over 6 weeks. Voucher monetary value started at $10 and escalated by $2.50 for each subsequent negative sample (maximum earnings: $367.50). Positive samples earned no vouchers and reset voucher value to $10, but two negative samples following a positive allowed participants to continue earning vouchers at the prereset value. Primary outcome was point-prevalence smoking abstinence at Week 6 assessment. More participants assigned to UC + HBCM than UC were smoking abstinent at that Week 6 assessment (90% vs. 30%), χ²(1, N = 20) = 7.5, p < .01. These results provide initial evidence that HBCM can effectively promote smoking abstinence in CVD outpatients. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Loss Aversion and Current, Former, and Never-Smoking Status.

INTRODUCTION: Loss aversion (LA) is a bias in decision-making wherein potential losses have a greater influence on choices than equivalent gains. Such a bias may protect individuals from harm. Consistent with this idea, lower LA has been measured in individuals who endorse current cigarette smoking as well as other substance use compared to controls matched on important sociodemographic variables (age, gender, and educational attainment). The goal of the present study was to systematically replicate and extend this association between LA and smoking status by comparing those meeting criteria for current-, former-, and never-smoking status. AIMS AND METHODS: In total, 984 individuals (N = 984) that endorsed current cigarette smoking (past 30-day use; n = 361), former-smoking (no past 30-day use, >100 cigarettes lifetime; n = 317), and never-smoking (no past 30-day use, <100 cigarettes lifetime; n = 306) were recruited using standard crowdsourcing methods and completed measures of LA (50-50 gambles) and delay discounting (DD) (monetary choice questionnaire), an important decision-making bias with an established relationship to cigarette-smoking status. RESULTS: Lower LA was observed in those endorsing current smoking compared to former smoking (t[952] = -9.57, Bonferroni corrected p < .0001), and never-smoking (t[952] = -3.99, Bonferroni corrected p = .0002). LA was also greater in former- compared to the never-smoking (t[952] = -5.26, Bonferroni corrected p < .0001). This pattern did not change when accounting for DD and sociodemographics. DD results replicated prior findings. CONCLUSIONS: The results support LA as a decision-making bias related to the risk of cigarette smoking and other substance use. Further research is needed to understand the causal contributions of LA and DD and their potential intersections. IMPLICATIONS: Low LA is a risk factor for cigarette smoking. This study reports higher LA among individuals that endorsed never-smoking and former-smoking status in comparison to those endorsing current cigarette smoking. LA may influence or be influenced by a change in smoking status.

Subjective experiences, contexts, and risk perceptions of very low nicotine content cigarettes and electronic cigarettes among people with depression and anxiety disorders who smoke.

BACKGROUND: A low-nicotine product standard is currently under consideration by the U.S. Food and Drug Administration (FDA). This standard may be more effective if alternative, non-combusted sources of nicotine are concurrently available. This qualitative study explored the lived experiences of people with depression and anxiety disorders who used very low nicotine content (VLNC) cigarettes with or without e-cigarettes during a randomized controlled trial. METHODS: We conducted semi-structured qualitative interviews with participants (n = 20) as they completed a 16-week blinded trial of VLNC cigarettes with or without electronic cigarettes. Interviews explored 1) experiences with these products, 2) social and environmental contexts for use and 3) relative risk perceptions. Interviews were transcribed and analyzed using a hybrid inductive and deductive thematic analysis. RESULTS: Concurrent access to e-cigarettes helped to ease the transition from usual-brand cigarettes to VLNC cigarettes. Some participants held misperceptions that VLNC cigarettes could reduce cancer risk whereas others did not. Participants expressed skepticism about the safety of e-cigarettes and the authenticity of the VLNC cigarettes. Smoking restrictions influenced e-cigarette use in some instances, but product preference was the overriding factor that influenced use. Participants did not note effects on psychiatric symptoms. CONCLUSIONS: Should a nicotine reduction policy be implemented with e-cigarettes concurrently available on the market, tailored messaging for people with anxiety and depression disorders may be necessary to educate people about and the availability of alternative sources of nicotine, such as e-cigarettes, as well as the relative risk of VLNC cigarettes and e-cigarettes.

Examining the latent factor structure of a hypothetical cigarette purchase task among pregnant women.

The cigarette purchase task (CPT) is a valid behavioral-economic measure of demand that has smokers estimate hypothetical cigarette consumption under a range of escalating prices. The task involves no experimenter exposure of participants to smoking. CPT demand is measured in terms of five indices: intensity (cigarettes consumed at $0), Omax (largest expenditure), Pmax (price associated with peak expenditure), breakpoint (the first price at which consumption is 0), and elasticity (rate at which consumption changes as a function of increasing price). Out of concern for collinearity, prior studies investigated a more parsimonious CPT latent-factor structure for these derived indices consisting of two factors. The present study examined whether the same two latent-factor solutions extend to pregnant women who smoke. Six hundred sixty-five women completed the CPT as part of recruitment for a clinical trial examining the efficacy of a remote contingency-management intervention to promote smoking cessation during pregnancy. Factor analysis confirmed a two-factor solution to the CPT accounting for 87% of the variance in the five indices with demand intensity and Omax loading onto amplitude and Omax, Pmax, breakpoint, and elasticity loading onto persistence. Backward elimination regression revealed a significant negative relationship between amplitude and persistence (i.e., lower amplitude and persistence scores predicted a higher likelihood of making at least one quit attempt upon learning of pregnancy). These results further support the utility of the CPT for experimentally examining individual differences in smoking among pregnant women in an efficient and ethical manner that does not involve exposing them to cigarette smoke. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Impact of the Covid-19 Pandemic on Smoking Among Vulnerable Populations.

AIM: While accumulating evidence suggests that people modified their smoking during the ongoing COVID-19 pandemic, it remains unclear whether those most at risk for tobacco-related health disparities did so. The current study examined changes in smoking among several vulnerable smoker populations during the COVID-19 pandemic. METHODS: A web-based survey was distributed in 2020 to 709 adults with socioeconomic disadvantage, affective disorders, or opioid use disorder who participated in a previous study investigating the effects of very low nicotine content (VLNC) cigarettes on smoking. Current smoking status and rate, and adoption of protective health behaviors in response to the pandemic (eg social distancing, mask wearing) were examined. RESULTS: Among 332 survey respondents (46.8% response rate), 84.6% were current smokers. Repeated measures ANOVA showed that current cigarettes/day (CPD) was higher during COVID than pre-COVID (12.9 ± 1.0 versus 11.6 ± 1.0; p < .001). Most respondents had adopted protective health behaviors to prevent infection (>79% for all behaviors). More than half indicated that they were still leaving their homes specifically to buy cigarettes (64.6%) and were buying more packs per visit to the store (54.5%) than pre-COVID. Individuals unemployed at the time of the survey experienced greater increases in CPD (from 11.4 ± 1.4 to 13.3 ± 1.4, p = .024) as did those with higher levels of anxiety (from 11.5 ± 1.1 to 13.6 ± 1.1, p < .001). CONCLUSIONS: Smoking increased during the COVID-19 pandemic in this sample of adults from vulnerable populations, even while most adopted protective health measures to prevent infection. Unemployment and anxiety might identify those at greatest risk for increases in tobacco use. IMPLICATIONS: Individuals from populations especially vulnerable to smoking might be at risk for greater harm from cigarette smoking during times of pandemic-related stress. Public health interventions are warranted to ameliorate increases in smoking among these populations. Special attention should be paid to those experiencing unemployment and high anxiety.

A review of research on cigarette smoking in Preventive Medicine in recognition of the journal's 50th anniversary.

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce cigarette smoking. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1181 articles on cigarette smoking: 1018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

Behavior change, health, and health disparities 2022: Innovations in tobacco control and regulatory science to decrease cigarette smoking.

This Special Issue of Preventive Medicine (PM) is the 9th in a series on behavior change, health, and health disparities. This topic is critically important to improving population health. Unhealthy lifestyles including substance misuse, unhealthy food choices, physical inactivity, and non-adherence with medical regimens are important preventable causes of chronic disease and premature death. This year we focus on cigarette smoking, which continues to have devastating health impacts including more than 8 million annual premature deaths globally and 480,000 in the U.S. where most of the research reported in this Special Issue was conducted. While the introduction of new tobacco products into the marketplace like electronic nicotine delivery systems (ENDS) demands attention, it is essential that we remain focused on the enormous challenges involved in eliminating cigarette smoking. This Special Issue examines innovations in tobacco control and regulatory science aimed towards reducing cigarette smoking. Discussion of new tobacco products is largely limited to their role in this overarching aim of reducing combusted cigarette use. We discuss important innovations in tobacco control (e.g., digital text-based interventions, ENDS-assisted cessation, financial incentives) and regulatory science (e.g., nicotine reduction in cigarettes, flavor bans). Throughout, attention is given to the important topic of disparities in terms of understanding the uneven adverse impacts of cigarette smoking and efforts to eliminate it, and the critical importance of researching vulnerable populations. Across these topics we have recruited contributions from accomplished investigators, clinicians, and policymakers to acquaint readers with recent advances while also noting knowledge gaps and unresolved challenges.

Relating individual differences in the reinforcing value of smoking and dependence severity to nicotine exposure levels in vulnerable populations.

Cigarette smoking is overrepresented in populations with psychiatric conditions and socioeconomic disadvantage. Greater understanding of the role of reinforcement and nicotine dependence in smoking among vulnerable populations may facilitate development of better targeted interventions to reduce smoking. Prior research demonstrated that individual differences in the reinforcing value of smoking and nicotine-dependence severity predicted total nicotine-exposure in vulnerable populations. The present study uses multivariate regression to address two aims: (1) Quantify the degree to which the reinforcing value of smoking, assessed using the Cigarette Purchase Task (CPT), and dependence severity assessed using the Fagerström Test of Nicotine Dependence and Brief Wisconsin Inventory of Smoking Dependence Motives (B-WISDM) each account for individual differences in cotinine-plus-3'-hydroxycotinine (COT+3HC) levels. (2) Explore whether there is overlap in the variance accounted for by the CTP, FTND, and B-WISDM. Participants were 628 adults with co-morbid psychiatric conditions or socioeconomic disadvantage who smoked daily. The CPT, FTND, and B-WISDM models accounted for 23.76%, 32.45%, and 29.61% of the variance in COT+3HC levels, respectively. Adding CPT to the FTND model failed to increase the variance accounted for and adding it to the B-WISDM model did so by only 1.2% demonstrating considerable overlap in the variance in nicotine exposure levels accounted for by these three instruments. These results provide new knowledge on the relationship between individual differences in the reinforcing value of smoking and nicotine-exposure levels and suggest differences in reinforcing value may underpin a considerable portion of the variance in nicotine exposure accounted for by dependence severity.

Potential effects of nicotine content in cigarettes on use of other substances.

A national nicotine reduction policy has the potential to reduce cigarette smoking and associated adverse health impacts among vulnerable populations. However, possible unanticipated adverse effects of reducing nicotine content in cigarettes, such as increasing the use of alcohol or other abused substances, must be examined. The purpose of this study was to evaluate the effects of exposure to varying doses of nicotine in cigarettes on use of other substances. This was a secondary analysis (n = 753) of three simultaneous, multisite, double-blind, randomized-controlled trials examining 12 weeks of exposure to study cigarettes varying in nicotine content (0.4, 2.4, 15.8 mg nicotine/g tobacco) among daily smokers from three vulnerable populations: individuals with affective disorders (n = 251), individuals with opioid use disorder (n = 256), and socioeconomically-disadvantaged women of reproductive age (n = 246). Effect of study cigarette assignment on urine toxicology screens (performed weekly) and responses to drug and alcohol use questionnaires (completed at study weeks 6 and 12) were examined using negative binomial regression, logistic regression, or repeated measures analysis of variance, controlling for sex, age, and menthol status. The most common substances identified using urine toxicology included tetrahydrocannabinol (THC; 44.8%), cocaine (9.2%), benzodiazepine (8.6%), and amphetamines (8.0%), with 57.2% of participants testing positive at least once for substance use (27.3% if excluding THC). No significant main effects of nicotine dose were found on any of the examined outcomes. These results suggest that reducing nicotine content does not systematically increase use of other substances, even among individuals at increased risk of substance use. ClinicalTrials.gov Identifiers: NCT02232737, NCT2250664, NCT2250534.