Is it "loud" enough?: A qualitative investigation of blunt use among African American young adults.

Heavy blunt use is common among young adult cannabis users, especially African Americans. This exploratory qualitative study aimed to examine how African American young adults understand, talk about and experience their blunt use. Semi-structured interviews were conducted with adults reporting daily or almost daily blunt use in the past month (N = 20; 75% male). Thematic analysis of the audio-recorded interviews revealed aspects of how blunts are described, made and used among heavy blunt users. The three emergent themes have implications for the assessment of cannabis use and intervention development for heavy blunt users.

Reductions in tobacco use in naltrexone, relative to buprenorphine-maintained individuals with opioid use disorder: Secondary analysis from the National Drug Abuse Treatment Clinical Trials Network.

BACKGROUND: Smoking prevalence in individuals with opioid use disorder (OUD) is over 80%. Research suggests that opioid use significantly increases smoking, which could account for the strikingly low smoking-cessation rates observed in both methadone- and buprenorphine-maintained patients, even with the use of first-line smoking-cessation interventions. If opioids present a barrier to smoking-cessation, then better smoking outcomes should be observed in OUD patients treated with extended-release naltrexone (XR-NTX, an opioid antagonist) compared to those receiving buprenorphine (BUP-NX, a partial opioid agonist). METHODS: The current study is a secondary analysis of a 24-week, multi-site, open-label, randomized clinical trial conducted within the National Drug Abuse Treatment Clinical Trials Network comparing the effectiveness of XR-NTX vs. BUP-NX for adults with OUD. Longitudinal mixed effects models were used to determine if there was a significant reduction in cigarette use among daily smokers successfully inducted to treatment (n = 373) and a subset of those who completed treatment (n = 169). RESULTS: Among daily smokers inducted onto OUD medication, those in the XR-NTX group smoked fewer cigarettes per day (M = 11.36, SE = 0.62) relative to smokers in the BUP-NX group (M = 13.33, SE = 0.58) across all study visits, (b (SE) = -1.97 (0.55), p < .01). Results were similar for the treatment completers. CONCLUSIONS: OUD patients treated with XR-NTX reduced cigarette use more than those treated with BUP-NX, suggesting that XR-NTX in combination with other smoking cessation interventions might be a better choice for OUD smokers interested in reducing their tobacco use.

Increased Morbidity and Mortality in Hypertensive Patients With Substance Use Disorders: Electronic Health Record Findings.

OBJECTIVE: Substance use disorder (SUD) management by medical providers may be important for patients with comorbid health conditions exacerbated by SUD. This study evaluated potential associations of SUD with morbidity and mortality in a large sample of hypertensive patients. METHOD: Analysis of a limited data set was obtained through IBM Watson Health Explorys, a platform integrating data from electronic health records. Matched controls were defined for each of five SUDs: tobacco use disorder (TUD), alcohol use disorder (AUD), cocaine use disorder (COUD), opioid use disorder (OUD), and cannabis use disorder (CUD) using Mahalanobis distance within propensity score calipers. All patients were from The MetroHealth System (Cleveland, OH) and had diagnosed hypertension. SUD group participants had diagnosed abuse/dependence for the substance of interest. Controls for each SUD group had no diagnosis code related to the substance of interest and were selected to match the SUD patients on several factors. Total sample sizes for each SUD-control comparison ranged from 3,176 (CUD) to 49,696 (TUD); proportions of female patients ranged from 31.7% (AUD) to 51.2% (TUD). Outcomes were diagnosis (yes/no) of the following: cerebrovascular accident, myocardial infarction, renal failure, and all-cause mortality. RESULTS: Logistic regressions revealed that SUD was significantly associated with cerebrovascular accident (odds ratios [ORs]: TUD = 2.23; AUD = 1.68; COUD = 2.53; OUD = 1.87; CUD = 2.20), renal failure (ORs: TUD = 1.46; COUD = 2.09; OUD = 1.77), myocardial infarction (ORs: TUD = 2.96; AUD = 1.92; COUD = 3.00), and mortality (ORs: TUD = 1.34; AUD = 1.60; COUD = 1.83; OUD = 1.35; CUD = 1.39). CONCLUSIONS: Among patients with hypertension, those with SUDs appear to have significantly greater risk for morbidity and mortality, suggesting the importance of managing SUD in hypertensive patients.

The association between regular cocaine use, with and without tobacco co-use, and adverse cardiovascular and respiratory outcomes.

BACKGROUND: Understanding the potential impact of cocaine use on health is increasingly important as cocaine use rises in the U.S. OBJECTIVES: This study evaluated the associations of regular cocaine use, with and without tobacco co-use, with cardiovascular and respiratory outcomes. METHODS: Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls were defined for: 1) cocaine-using patients (n = 8244; 44 % female); and subgroups of cocaine-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4706); and 3) without a TUD diagnosis (non-TUD; n = 3538). Patients had at least one documented medical evaluation in the MetroHealth System (Cleveland, Ohio). Cocaine-using patients had an encounter diagnosis of cocaine abuse/dependence and/or ≥2 cocaine-positive drug screens. Control patients, with no documented cocaine-use, were matched to the cocaine-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident, heart arrhythmia, myocardial infarction, subarachnoid hemorrhage, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and all-cause mortality. RESULTS: TUD-patients had the greatest prevalence of cardiovascular and respiratory disease, regardless of cocaine-use indication. In the total sample, TUD, and non-TUD subgroups, regular cocaine use was significantly associated with greater risk for cerebrovascular accident, arrhythmia, myocardial infarction, asthma, COPD, pneumonia and mortality. CONCLUSIONS: Cocaine use is associated with significantly greater risk of adverse cardiovascular and respiratory diagnoses and all-cause mortality.

The association between regular cannabis use, with and without tobacco co-use, and adverse cardiovascular outcomes: cannabis may have a greater impact in non-tobacco smokers.

BACKGROUND: Understanding the potential impact of cannabis use on cardiovascular health is increasingly important as cannabis use rises in the U.S. Objectives: This study evaluated the associations between regular cannabis use, with and without tobacco co-use, and cardiovascular outcomes. METHODS: Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8,944; 43% female); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4,682); and 3) without a TUD diagnosis (non-TUD; n = 4,262). Patients had ≥1 blood pressure measurement and blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens. Control patients, with no cannabis-use-documentation, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident (CVA), heart arrhythmia, myocardial infarction, subarachnoid hemorrhage (SAH), and all-cause mortality. RESULTS: TUD-patients had the greatest prevalence of cardiovascular disease, regardless of cannabis-use indication. In the total sample and non-TUD subgroup, regular cannabis use was significantly associated with greater risk for CVA, arrhythmia, SAH, and mortality. In the TUD subgroup, regular cannabis use was significantly associated with greater risk for arrhythmia and SAH. CONCLUSIONS: Cannabis use is associated with significantly greater risk of adverse cardiovascular diagnoses and overall death, particularly in non-tobacco users.

Blunt use and menthol cigarette smoking: An examination of adult marijuana users.

INTRODUCTION: Use of menthol cigarettes remains highly prevalent among African American smokers and has increased among White and Hispanic/Latino smokers. Research is needed to examine if behavioral factors, such as marijuana use, are differentially associated with menthol cigarette use among racially/ethnically diverse samples of marijuana users. METHODS: Using data from the 2017 National Survey on Drug Use and Health, this study examined the association between past month marijuana (blunt versus non-blunt) and cigarette (non-menthol cigarette versus menthol cigarette versus no cigarette) use, as well as racial/ethnic differences in this relationship. RESULTS: Among all marijuana users (N = 5,137), 34.1% smoked blunts, 28.7% smoked non-menthol cigarettes and 18.0% smoked menthol cigarettes, with the highest rates of blunt (63.8%) and menthol cigarette (38.9%) use found among African American adults. Multinomial logistic regression analyses revealed a significant association between blunt use and non-menthol cigarette use (versus non-use) and menthol cigarette use (versus non-menthol cigarette and no cigarette use) among the full sample. When stratified by race/ethnicity, this finding was consistent for non-Hispanic White (n = 3,492) and partially consistent for Hispanic/Latino (n = 839) adults. However, among African American adults (n = 806), blunt use was not significantly associated with non-menthol cigarette use or menthol cigarette use. DISCUSSION: Blunt use is associated with increased odds of non-menthol and menthol cigarette use, but only among Hispanic/Latino and White adults. Examining racial/ethnic differences in the association between marijuana and tobacco use is important to understanding disparities and informing prevention and treatment interventions and drug policies.

Differential Posttreatment Outcomes of Methylphenidate for Smoking Cessation for Individuals With ADHD.

BACKGROUND AND OBJECTIVES: In a multisite, randomized study (CTN-0029), a 3-month course of Osmotic-Release Oral System Methylphenidate (OROS-MPH) improved smoking cessation in a group of patients with higher baseline severity in Attention-Deficit/Hyperactivity Disorder (ADHD). This treatment, however, worsened smoking cessation outcome in the group with lower baseline ADHD severity. We want to examine whether this differential treatment effect persisted after OROS-MPH was discontinued. METHODS: We conducted a secondary analysis of the 1-month follow-up data from CTN-0029 after the discontinuation of OROS-MPH (N = 134). Nicotine patch was tapered during this month. We tested whether OROS-MPH had an effect on self-reported 7-day abstinence by week, as well as possible treatment by baseline ADHD severity interactions. RESULTS: Abstinence diminished overall in time after the end of the treatment. In the high baseline severity group, patients who received OROS-MPH had an advantage in 7-day abstinence at week 15 (40% for OROS-MPH vs 20% for placebo, odds ratio = 2.63, P = .028). In the lower severity group (n = 121), no difference was detected (29% for OROS-MPH vs 32% for placebo, P = 1.00) between the two treatment groups. There was also a significant treatment by baseline ADHD severity interaction (P = .03). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: OROS-MPH promotes abstinence beyond the course of treatment for patients with more severe ADHD, while the paradoxical effects in the lower baseline severity group is not persistent after medication discontinuation. Targeting ADHD in smoking cessation as a comorbidity therefore can have broader impact with more precise patient selection. (Am J Addict).

Regular cannabis use, with and without tobacco co-use, is associated with respiratory disease.

BACKGROUND: Cannabis use is a potential risk factor for respiratory disease but its role apart from tobacco use is unclear. We evaluated the association between regular cannabis use, with and without tobacco co-use, and onset of asthma, chronic obstructive pulmonary disease (COPD), and pneumonia. METHODS: Analysis of a limited data set obtained through IBM Watson Health Explorys, an electronic-health-record-integration platform. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8932); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4678); and 3) without a TUD diagnosis (non-TUD; n = 4254). Patients had at least: one recorded blood pressure measurement and one blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens (UDSs). Control patients, not having cannabis-related diagnoses or cannabis-positive UDSs, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. RESULTS: Regular cannabis use was significantly associated with greater risk for asthma (odds ratio (OR) = 1.44; adjusted odds ratio (aOR) = 1.50; OR = 1.32), COPD (OR = 1.56; aOR = 1.44; OR = 2.17), and pneumonia (OR = 1.80; OR = 1.84; OR = 2.13) in the total sample and TUD and non-TUD subgroups, respectively. TUD-patients had the greatest prevalence of respiratory disease, regardless of cannabis-use indication. CONCLUSIONS: Regular cannabis use is associated with significantly greater risk of respiratory disease regardless of TUD status. Future research to understand the impact of cannabis use on respiratory health is warranted.

Medical complications associated with substance use disorders in patients with type 2 diabetes and hypertension: electronic health record findings.

BACKGROUND AND AIMS: Screening for substance use disorder (SUD) in general medical settings may be particularly important in patients with comorbid health conditions exacerbated by SUD. This study evaluated whether SUD is associated with type 2 diabetes mellitus (T2DM) complications in patients with co-occurring T2DM and hypertension. DESIGN: Analysis of a limited data set obtained through IBM Watson Health Explorys, a platform integrating data from electronic health records. Matched controls were defined for each of five SUDs: tobacco use disorder (TUD), opioid use disorder (OUD), cocaine use disorder, cannabis use disorder (CUD) and alcohol use disorder (AUD) using Mahalanobis distance within propensity score calipers. SETTING: All patients were seen in the MetroHealth System (Cleveland, OH, USA) and had diagnosis codes for T2DM and hypertension. PARTICIPANTS: SUD group participants had a diagnosis of abuse/dependence for the substance of interest. Controls for each SUD group had no diagnosis code related to the SUD of interest and were selected to match the SUD patients on demographics, residential zip code median income and body mass index. Total sample sizes for each SUD-control comparison ranged from 1160 for CUD to 22 128 for TUD. MEASUREMENTS: Outcome was diagnosis (yes/no) of four T2DM complications (cerebrovascular accident, diabetic neuropathy, diabetic renal disease, myocardial infarction) and all-cause mortality. FINDINGS: Logistic regressions revealed that SUD was significantly associated with greater risk of cerebrovascular accident [TUD odds ratio (OR) = 1.79, OUD-OR = 1.94, cocaine use disorder OR = 2.67], diabetic neuropathy [TUD-adjusted OR (aOR) = 1.47, cocaine use disorder-aOR = 1.35, AUD-aOR = 1.27], diabetic renal disease (TUD-aOR = 1.25, OUD-OR = 1.34), myocardial infarction (TUD-OR = 1.96, OUD-OR = 2.01, cocaine use disorder-OR = 2.68, CUD-OR = 2.48, AUD-OR = 1.42) and mortality (TUD-OR = 1.15, cocaine use disorder-OR = 1.61, CUD-OR = 1.49, AUD-OR = 1.35). CONCLUSIONS: Among patients in Ohio USA with both type 2 diabetes mellitus (T2DM) and hypertension, those with substance use disorders appear to have greater risk for T2DM complications and all-cause mortality.

Blunts versus joints: Cannabis use characteristics and consequences among treatment-seeking adults.

BACKGROUND: Despite the high prevalence of blunt smoking among cannabis users, very few studies examine the clinical profile of blunt smokers relative to those using more common methods of cannabis use, such as joints. METHODS: The current study uses baseline data from the ACCENT (Achieving Cannabis Cessation-Evaluating N-acetylcysteine Treatment) study, a multi-site randomized pharmacotherapy clinical trial within the National Drug Abuse Treatment Clinical Trials Network, to predict the association between blunt and joint use frequency and cannabis use characteristics (e.g., grams of cannabis used) and consequences (e.g., withdrawal) among past-month cannabis users (N = 377) who were screened for study participation. RESULTS: After controlling for race, age, gender, other forms of cannabis use (including joint use) and nicotine dependence, multivariable linear regression models indicated that the number of days of blunt use in the past month was a significant predictor of the average amount of cannabis per using day (t = 3.04, p < .01), the estimated average cost of cannabis (t = 2.28, p < .05) and Cannabis Withdrawal Scale scores (t = 1.94, p < .05). Frequency of joint use did not significantly predict any of the cannabis use characteristics or consequences. CONCLUSIONS: Blunt smokers may present to treatment with greater amounts of cannabis smoked and more intense withdrawal symptoms, which may adversely impact their likelihood of successful abstinence. Cannabis-dependent blunt smokers may be more likely to benefit from treatment that targets physiological and mood-related withdrawal symptoms.

Substance use outcomes in cocaine-dependent tobacco smokers: A mediation analysis exploring the role of sleep disturbance, craving, anxiety, and depression.

BACKGROUND: Sleep disturbance may play a role in cocaine use outcomes and, hence, may be a potential therapeutic target for cocaine use disorder (CUD). Research in this area, which has largely relied on resource-intensive polysomnography, would be facilitated by identifying a self-report sleep measure predictive of CUD outcomes and by a better understanding of the mechanisms by which sleep may impact CUD outcomes. This study tested the predictive validity of the Pittsburgh Sleep Quality Index (PSQI), a self-report assessment of past-month sleep quality. To better understand potential mechanisms, mediation models relating sleep disturbance to CUD outcomes were evaluated. METHODS: This is a secondary analysis of data from cocaine-dependent (n = 290) participants in a multi-site trial evaluating smoking-cessation treatment for stimulant-dependent patients. The PSQI was collected at baseline; the outcomes of interest were cocaine and drug abstinence at end-of-treatment (weeks 9-10). Potential mediators, measured in weeks 1-8, were: cocaine craving (Brief Substance Craving Scale); and anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Mediation techniques were used to evaluate mediation effects separately and jointly. RESULTS: The majority of participants (58.3%) had baseline sleep disturbance. Sleep disturbance was not a significant predictor of end-of-treatment abstinence when regressed without consideration of mediators. Cocaine craving, anxiety, and depression were significant mediators, both separately and jointly, of an effect of baseline sleep disturbance on end-of-treatment abstinence. CONCLUSION: This exploratory analysis suggests that there may be an indirect relationship between self-reported sleep quality and substance use outcomes in cocaine-dependent patients, mediated by craving, anxiety, and depression. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01077024.

Exploring longitudinal course and treatment-baseline severity interactions in secondary outcomes of smoking cessation treatment in individuals with attention-deficit hyperactivity disorder.

BACKGROUND: A double blind, placebo-controlled randomized trial (NCT00253747) evaluating osmotic-release oral system methylphenidate (OROS-MPH) for smoking-cessation revealed a significant interaction effect in which participants with higher baseline ADHD severity had better abstinence outcomes with OROS-MPH while participants with lower baseline ADHD severity had worse outcomes. OBJECTIVES: This current report examines secondary outcomes that might bear on the mechanism for this differential treatment effect. METHODS: Longitudinal analyses were conducted to evaluate the effect of OROS-MPH on three secondary outcomes (ADHD symptom severity, nicotine craving, and withdrawal) in the total sample (N = 255, 56% Male), and in the high (N = 134) and low (N = 121) baseline ADHD severity groups. RESULTS: OROS-MPH significantly improved ADHD symptoms and nicotine withdrawal symptoms in the total sample, and exploratory analyses showed that in both higher and lower baseline severity groups, OROS-MPH statistically significantly improved these two outcomes. No effect on craving overall was detected, though exploratory analyses showed statistically significantly decreased craving in the high ADHD severity participants on OROS-MPH. No treatment by ADHD baseline severity interaction was detected for the outcomes. CONCLUSIONS: Methylphenidate improved secondary outcomes during smoking cessation independent of baseline ADHD severity, with no evident treatment-baseline severity interaction. Our results suggest divergent responses to smoking cessation treatment in the higher and lower severity groups cannot be explained by concordant divergence in craving, withdrawal and ADHD symptom severity, and alternative hypotheses may need to be identified.

Baseline Cigarette Smoking Status as a Predictor of Virologic Suppression and CD4 Cell Count During One-Year Follow-Up in Substance Users with Uncontrolled HIV Infection.

Cigarette smoking is prevalent in people living with HIV/AIDS (PLHIV) who abuse alcohol and/or illicit substances. This study evaluated whether smoking is predictive of virologic non-suppression (> 200 copies/mL) and low CD4 count (< 200 cells/mm3) during 1-year follow-up in medically hospitalized, substance-using PLHIV recruited for a multi-site trial. Smoking status was assessed with the Heaviness of Smoking Index (HSI). Analyses revealed that, controlling for baseline differences and adherence to antiretroviral therapy, non-smokers (n = 237), compared to smokers scoring in the medium-to-high range on the HSI (n = 386), were significantly more likely to achieve viral suppression (OR 1.50, 95% CI 1.02, 2.20). There was a significant smoking-by-time interaction for CD4 cell count (χ2(1) = 4.08, p < .05), with smokers less likely to have low CD4 count at baseline and 6-month follow-up, but more likely to have low CD4 count at 12-month follow-up. The results suggest that smoking may play a role in immunological functioning in HIV-infected substance users. ClinicalTrials.gov Identifier: NCT01612169.

The association between cigarette smoking, virologic suppression, and CD4+ lymphocyte count in HIV-Infected Russian women.

Cigarette smoking among people living with HIV/AIDS is associated with significant morbidity and mortality, but findings regarding the association between cigarette smoking and HIV viral load and CD4+ lymphocyte counts have been inconsistent. This study characterized the prevalence of cigarette smoking among HIV-infected Russian women and examined the association between smoking frequency and quantity and HIV viral load and CD4+ lymphocyte counts. HIV-infected Russian women (N = 250; M age = 30.0) in St. Petersburg, Russia, completed an audio computer-assisted self-interview survey assessing cigarette use, antiretroviral medication adherence, and provided blood samples assayed for HIV viral load and CD4+ lymphocyte counts. The majority (60.4%) reported cigarette smoking in the past month; 49.0% of recent smokers were classified as moderate or heavy smokers, defined as smoking ≥10 cigarettes daily. Viral load status did not differ between infrequent smokers and regular smokers. However, moderate/heavy smokers (relative to light smokers) were more likely to have a detectable viral load (AOR = 2.3, 95% CI: 1.1, 5.1). There were no significant differences in CD4+ lymphocyte counts by smoking frequency or quantity of cigarettes smoked. Results highlight the need for additional research to examine the association between cigarette smoking and virologic suppression and markers of HIV disease progression. Adverse health consequences of cigarette smoking coupled with a potential link between heavy smoking and poor virologic suppression highlight the need for assessment of cigarette use and provision of evidence-based smoking-cessation interventions within HIV medical care.

Cigarette smoking in pregnant substance users: Association with substance use and desire to quit.

Cigarette smoking is prevalent in pregnant substance users but receives low priority in substance use disorder treatment. This article reports the results of a secondary analysis of a randomized, multisite trial with 200 pregnant substance users, 145 (72.5%) of whom smoked at baseline. As predicted: (1) smokers had significantly greater substance use; (2) approximately half of smokers wanted to quit; and (3) smokers with a quit goal had significantly greater self-efficacy and lower perceived difficulty of quitting. Smoking may be associated with more severe substance use in pregnant substance-using patients, half of whom may be interested in smoking-cessation interventions.

Design considerations for a pilot trial using a novel approach for evaluating smoking-cessation medication in methadone-maintained smokers.

The prevalence of smoking in methadone-maintained (MM) patients is over 80% and smoking-abstinence rates are strikingly low, even with the use of first-line smoking-cessation medications. Research has found that cigarettes increase the reinforcing properties of methadone; this interaction may be an additional, daily, challenge to smoking cessation in MM-smokers. This paper describes a novel approach in which patients who experience a particular barrier to achieving smoking abstinence are selected, and the impact of smoking-cessation medications on the identified barrier is evaluated. This is a 7-week, outpatient, randomized, within-subject, placebo-controlled, crossover trial with a follow-up visit at week 8. MM-smokers, who smoke ≥40% of their total daily cigarettes in the 4-h post-methadone-dosing period, as assessed with a Quitbit electronic cigarette lighter, will be recruited from a methadone program in Cincinnati, Ohio. Eligible participants will be randomized to receive four interventions (nicotine nasal spray (1mg per dose, up to 40 times per day), placebo nicotine nasal spray, varenicline (2mg/day), and varenicline placebo) in one of four orders to mitigate potential order effects. The primary outcome analysis will consist of two sets of statistical analyses, one comparing the effect of nicotine nasal spray to its placebo, and one comparing the effect of varenicline to its placebo, on the proportion of daily cigarettes smoked during the 4-h post-methadone-dosing period. This trial is of interest both as an efficient, precision-medicine-based approach to testing smoking-cessation interventions and as a specific strategy for identifying effective smoking-cessation treatment for MM-smokers.

The coupling of nicotine and stimulant craving during treatment for stimulant dependence.

OBJECTIVE: Smoking prevalence is high among substance abusers, making it important to understand when nicotine abstinence will aid, impair, or not affect abstinence from other substances. This study tested novel hypotheses about the coupling of nicotine and stimulant craving over time during stimulant dependence treatment. METHOD: Adults (N = 538) with cocaine and/or methamphetamine dependence completed a 10-week randomized controlled trial of substance use treatment with or without smoking cessation treatment. Participants reported nicotine and stimulant craving weekly and use twice per week. RESULTS: Latent change score modeling tested the association between weekly increases in nicotine craving and subsequent weekly changes in stimulant craving. Interestingly, results revealed a "substitution" effect: increases in nicotine craving predicted subsequent decreases in stimulant craving, γ = -.37, p = .001. Additionally, increases in nicotine craving predicted subsequent increases in nicotine use, γ = 1.26, p = .04, and decreases in stimulant use, γ = -.07, p = .03. As expected, the substitution effect between nicotine and stimulant craving was stronger when stimulants were administered through the same route as nicotine (i.e., smoking), γ = -.56, p = .005, versus other routes, γ = -.32, p = .06. Finally, smoking cessation treatment eliminated the coupling between nicotine craving and stimulant craving, γ = -.07, p = .39. CONCLUSIONS: Contrary to concerns about nicotine abstinence during substance dependence treatment, increases in nicotine craving may be associated with later reductions in stimulant craving and use, and unrelated when smoking cessation treatment is introduced. Weekly changes in nicotine craving convey information that can help clinicians to predict and understand shifts in stimulant craving and use during substance use disorder treatment.

Evaluating Nicotine Craving, Withdrawal, and Substance Use as Mediators of Smoking Cessation in Cocaine- and Methamphetamine-Dependent Patients.

INTRODUCTION: Smoking is highly prevalent in substance dependence, but smoking-cessation treatment (SCT) is more challenging in this population. To increase the success of smoking cessation services, it is important to understand potential therapeutic targets like nicotine craving that have meaningful but highly variable relationships with smoking outcomes. This study characterized the presence, magnitude, and specificity of nicotine craving as a mediator of the relationship between SCT and smoking abstinence in the context of stimulant-dependence treatment. METHODS: This study was a secondary analysis of a randomized, 10-week trial conducted at 12 outpatient SUD treatment programs. Adults with cocaine and/or methamphetamine dependence (N = 538) were randomized to SUD treatment as usual (TAU) or TAU+SCT. Participants reported nicotine craving, nicotine withdrawal symptoms, and substance use in the week following a uniform quit attempt of the TAU+SCT group, and self-reported smoking 7-day point prevalence abstinence (verified by carbon monoxide) at end-of-treatment. RESULTS: Bootstrapped regression models indicated that, as expected, nicotine craving following a quit attempt mediated the relationship between SCT and end-of-treatment smoking point prevalence abstinence (mediation effect = 0.09, 95% CI = 0.04% to 0.14%, P < .05, 14% of total effect). Nicotine withdrawal symptoms and substance use were not significant mediators (Ps > .05, <1% of total effect). This pattern held for separate examinations of cocaine and methamphetamine dependence. CONCLUSIONS: Nicotine craving accounts for a small but meaningful portion of the relationship between smoking-cessation treatment and smoking abstinence during SUD treatment. Nicotine craving following a quit attempt may be a useful therapeutic target for increasing the effectiveness of smoking-cessation treatment in substance dependence.

Anxiety and Depressed Mood Decline Following Smoking Abstinence in Adult Smokers with Attention Deficit Hyperactivity Disorder.

INTRODUCTION: A preponderance of relevant research has indicated reduction in anxiety and depressive symptoms following smoking abstinence. This secondary analysis investigated whether the phenomenon extends to smokers with attention deficit hyperactivity disorder (ADHD). METHODS: The study setting was an 11-Week double-blind placebo-controlled randomized trial of osmotic release oral system methylphenidate (OROS-MPH) as a cessation aid when added to nicotine patch and counseling. Participants were 255 adult smokers with ADHD. The study outcomes are: anxiety (Beck Anxiety Inventory (BAI)) and depressed mood (Beck Depression Inventory II (BDI)) measured one Week and six Weeks after a target quit day (TQD). The main predictor is point-prevalence abstinence measured at Weeks 1 and 6 after TQD. Covariates are treatment (OROS-MPH vs placebo), past major depression, past anxiety disorder, number of cigarettes smoked daily, demographics (age, gender, education, marital status) and baseline scores on the BAI, BDI, and the DSM-IV ADHD Rating Scale. RESULTS: Abstinence was significantly associated with lower anxiety ratings throughout the post-quit period (p<0.001). Depressed mood was lower for abstainers than non-abstainers at Week 1 (p<0.05), but no longer at Week 6 (p=0.83). Treatment with OROS-MPH relative to placebo showed significant reductions at Week 6 after TQD for both anxiety (p<0.05) and depressed mood (p<0.001), but not at Week 1. Differential abstinence effects of gender were observed. Anxiety and depression ratings at baseline predicted increased ratings of corresponding measures during the post-quit period. CONCLUSION: Stopping smoking yielded reductions in anxiety and depressed mood in smokers with ADHD treated with nicotine patch and counseling. Treatment with OROS-MPH yielded mood reductions in delayed manner.