Leveraging the cigarette purchase task to understand relationships between cumulative vulnerabilities, the relative reinforcing effects of smoking, and response to reduced nicotine content cigarettes.

We examined if the relative-reinforcing effects of smoking increase with greater cumulative vulnerability and whether cumulative vulnerability moderates response to reduced nicotine content cigarettes. Participants were 775 adults from randomized clinical trials evaluating research cigarettes differing in nicotine content (0.4, 2.4, 15.8 mg/g). Participants were categorized as having low (0-1), moderate (2-3), or high (≥4) cumulative vulnerability. Vulnerabilities included rural residence, opioid use disorder, affective disorder, low educational attainment, poverty, unemployment, and physical disability. We used the cigarette purchase task (CPT) to assess the relative-reinforcing effects of participants' usual-brand cigarettes at baseline and study cigarettes during the 12-week trial. The CPT is a behavioral-economic task wherein participants estimate likely smoking (demand) over 24 h under escalating cigarette price. Demand is characterized by two factors: Amplitude (demand volume at zero/minimal price) and Persistence (demand sensitivity to price). Greater cumulative vulnerability was associated with greater demand Amplitude (F[2709] = 16.04,p < .0001) and Persistence (F[2709] = 8.35,p = .0003) for usual-brand cigarettes. Demand Amplitude for study cigarettes increased with increasing cumulative vulnerability (F[2619] = 19.59, p < .001) and decreased with decreasing nicotine content ([4879] = 5.45, p < .001). The only evidence of moderation was on demand Persistence (F[8867] = 2.00,p = .04), with larger reductions at the 0.4 mg/g compared to 15.8 mg/g doses among participants with low compared to moderate or high cumulative vulnerability. The relative-reinforcing effects of smoking clearly increase with greater cumulative vulnerability. Reducing nicotine content would likely reduce demand Amplitude across cumulative-vulnerability levels but reductions in demand Persistence may be more limited among those with greater cumulative vulnerability.

A Meta-Analysis of Cue Reactivity in Tobacco Cigarette Smokers.

INTRODUCTION: The cue reactivity paradigm allows for systematic evaluation of motivational responses to drug-related cues that may elicit drug use. The literature on this topic has grown substantially in recent decades, and the methodology used to study cue reactivity has varied widely across studies. The present research provided a meta-analytic investigation of variables that have an impact on cue reactivity effects to enhance our understanding of this key feature of tobacco use disorders. METHODS: A total of 128 publications yielded 249 effect sizes, which were analyzed to investigate the magnitude of the cue reactivity effect and potential moderators. RESULTS: Craving generated a moderate-to-large effect size (Hedges' g = 0.71, p < .001), indicating that drug cues produced significantly greater craving than neutral cues. However, physiological variables yielded significantly lower or nonsignificant effect sizes. Analyses of a variety of empirically and theoretically relevant moderator variables showed that cue modality, cue personalization, cue reactivity environment, and the use of multiple assessments of cue reactivity were significantly associated with the magnitude of cue-specific craving effects (ps < .001). Effect sizes were not significantly related to abstinence status, gender, cigarettes per day, and treatment-seeking status. CONCLUSIONS: The results underscored the strength of self-reported craving as an index of cue reactivity across studies, which support theories that posit cue reactivity is core to the addictive process for daily tobacco cigarette smokers. The present research further elucidates the variables that alter the cue reactivity effects across studies and provides recommendations for future cue reactivity research. IMPLICATIONS: A core feature of addiction is that drug-related cues can have a major impact on motivational responses across multiple substance use disorders, including tobacco cigarettes. This paper describes a meta-analysis updating and synthesizing cue reactivity research with tobacco cigarette smokers over the last 20 years, a time of rapid growth for this literature. The study leads to a better understanding of the cue reactivity paradigm across different self-report and physiological variables and identifies factors that may modulate addictive motivation for tobacco cigarettes.

Vaping Restrictions: Is Priority to the Young Justified?

The vast majority of smokers become dependent on nicotine in youth. Preventing dependence has therefore been crucial to the recent decline in youth smoking. The advent of vaping creates an opportunity for harm reduction to existing smokers (mostly adults) but simultaneously also undermines prevention efforts by becoming a new vehicle for young people to become dependent on nicotine, creating an ethical dilemma. Restrictions to access to some vaping products enacted in response to the increase in vaping among youth observed in the United States since 2018 have arguably prioritized prevention of new cases of dependence-protecting the young-over harm reduction to already dependent adults. Can this prioritization of the young be justified? This article surveys the main bioethical arguments for prioritizing giving health benefits to the young and finds that none can justify prioritizing dependence prevention over harm reduction: any reasons for prioritizing the current cohort of young people at risk from vaping will equally apply to current adult smokers, who are overwhelmingly likely to have become nicotine-dependent in their own youth. Public health authorities' current tendency to prioritize the young, therefore, does not seem to be ethically justified. IMPLICATIONS: This article argues that commonsense reasons for prioritizing the young do not apply to the ethical dilemma surrounding restricting access to vaping products.

Smokers' Exposure to Perceived Modified Risk Claims for E-Cigarettes, Snus, and Smokeless Tobacco in the United States.

INTRODUCTION: Based on arguments for harm reduction and health benefits, tobacco companies in the United States can apply for regulatory authorization to make "modified risk tobacco product" (MRTP) marketing claims. The impact of future MRTP claims may depend on whether they are noticed, believed, and lead to smokers switching products. This study provides baseline data about smokers' exposure to perceived MRTP claims ahead of any MRTP authorizations. AIMS AND METHODS: We analyzed measures from Wave 3 of the US-based Population Assessment of Tobacco and Health (PATH) study which asked smokers to indicate if they had seen any e-cigarettes, snus, or other smokeless tobacco (SLT) products that claim to be "less harmful" in the past 12 months, and their likelihood of using products with these claims in the next 30 days. RESULTS: Significantly fewer smokers noted having seen snus (5.1%) or other SLT (5.6%) with "less harmful" claims compared with e-cigarettes (29.1%). For each product, the prevalence of MRTP claim exposure was higher among smokers who perceived the product to be less harmful than smoking, who currently used the product, and who had higher rates of tobacco advertising exposure at the point of sale. Among smokers who noticed products with "less harmful" claims, about one-quarter said they would use them in the future (24%-27%). CONCLUSIONS: Ahead of any Food & Drug Administration (FDA) authorization for MRTP claims, some smokers already perceive exposure to "less harmful" claims for e-cigarettes, but few do for SLT. MRTP claims may motivate some smokers to use these products. IMPLICATIONS: This study provides new baseline data about smokers' perceived exposure to MRTP claims in the United States ahead of any regulatory claim authorization. Using data from Wave 3 of the US PATH study, we found that some smokers already perceive exposure to "less harmful" claims for e-cigarettes (29%), but few do for SLT (5%-6%). Among smokers who noticed products with "less harmful" claims, about one-quarter said they would use them in the future (24%-27%), suggesting MRTP claims may motivate some smokers to use products described as "less harmful."

Testing Augmented Reality for Eliciting Cue-Provoked Urges to Smoke: Toward Moving Cue-Exposure Into the Real World.

BACKGROUND: Cue exposure for extinguishing conditioned urges to smoking cues has been promising in the laboratory, but difficult to implement in natural environments. The recent availability of augmented reality (AR) via smartphone provides an opportunity to overcome this limitation. Testing the ability of AR to elicit cue-provoked urges to smoke (ie, cue reactivity [CR]) is the first step to systemically testing the efficacy of AR for cue exposure therapy. OBJECTIVES: To test CR to smoking-related AR cues compared to neutral AR cues, and compared to in vivo cues. METHODS: A 2 × 2 within-subject design comparing cue content (smoking vs. neutral) and presentation modality (AR vs. in vivo) on urge response. Seventeen smokers viewed six smoking-related and six neutral cues via AR smartphone app and also six smoking and six neutral in vivo cues. Participants rated their urge to smoke and reality/co-existence of the cue. RESULTS: Average urge to smoke was higher following smoking-related AR images (Median = 7.50) than neutral images (Median = 3.33) (Z = -3.44; p = .001; d = 1.37). Similarly, average urge ratings for in vivo smoking-related cues (Median = 8.12) were higher than for neutral cues (Median = 2.12) (Z = -3.44; p = .001; d = 1.64). Also, greater CR was observed for in vivo cues than for AR cues (Z = -2.67, p = .008; d = .36). AR cues were generally perceived as being realistic and well-integrated. CONCLUSIONS: CR was demonstrated with very large effect sizes in response to AR smoking cues, although slightly smaller than with in vivo smoking cues. This satisfies the first criterion for the potential use of AR for exposure therapy. IMPLICATIONS: This study introduces AR as a novel modality for presenting smoking-related stimuli to provoke cue reactivity, and ultimately to conduct extinction-based therapy. AR cues presented via a smartphone have the advantage over other modes of cue presentation (pictures, virtual reality, in vivo, etc.) of being easily transportable, affordable, and realistic, and they can be inserted in a smokers' natural environment rather than being limited to laboratory and clinic settings. These AR features may overcome the generalizability barriers of other methods, thus increasing clinical utility for cue exposure therapies.

Impact of the Revised European Tobacco Product Directive on the Quality of E-cigarette Refill Liquids in Belgium.

INTRODUCTION: Since its introduction, the e-cigarette has become a commonly used consumer product. In this study, we investigate whether regulatory changes had an impact on the quality of refill liquids (e-liquids) available on the Belgian market through analysis of their chemical composition. Hence, the nicotine concentration accuracy was investigated in samples before, during and after the implementation of the revised Tobacco Product Directive (TPD) as an indicator of good manufacturing practices. This is, however, not enough to assure the quality. Therefore, extra criteria were also assessed based on TPD requirements. METHODS: By using in-house validated methods, a total of 246 e-liquids purchased prior (2013-2015), during (2016) and after (2017-2018) the implementation of the TPD revisions, were analyzed for the presence of nicotine, nicotine-related impurities, volatile organic compounds (VOCs), caffeine and taurine, and the flavors diacetyl and acetylpropionyl. RESULTS: Although not all manufacturers managed to produce and label their products accurately, nicotine labeling discrepancies have decreased over time. Moreover, also the number of e-liquids, containing high-risk VOCs (10% in 2016 vs. none of the samples in 2017-2018), caffeine (16% in 2017 vs. 5% in 2018), and diacetyl and acetylpropionyl (50% in 2017 vs. 27% in 2018 of sweet-flavored samples) diminished over time. CONCLUSION: Our results demonstrate that the overall quality of the e-liquids has improved after the implementation of the revised TPD. However, the results also show that periodic quality control might be required to ensure further compliance to the TPD. IMPLICATIONS: This study clearly demonstrates that the implementation of the revised TPD has improved the quality of the e-liquids on the Belgian market. However, there are still e-liquids that are not in agreement with the TPD due to nicotine concentration label discrepancies, presence of e-liquid impurities and controversial flavors diacetyl and acetylpropionyl or the additive caffeine.

Tobacco Product Promotions Remain Ubiquitous and Are Associated with Use and Susceptibility to Use Among Adolescents.

INTRODUCTION: The decline in tobacco smoking among US adolescents has been exceeded by the exponential rise in nicotine vaping with an overall net gain in youth tobacco product use. While cigarette companies are restricted from advertising on television/radio, vaping promotions have been largely unrestricted. This study examined exposure to tobacco product promotions in a US sample of 1003 adolescents and its associations with product use and susceptibility to use. AIMS AND METHODS: Adolescents (13-17) were recruited online and anonymously surveyed in 2019 about their ever and current (past 30 days) tobacco smoking (cigarette and cigar) and nicotine vaping behaviors, and among never-users, susceptibility to vaping. Multivariate models tested associations with past-month exposure to tobacco product promotions controlling for demographic features, harm perceptions, and family and peer influences. RESULTS: Tobacco product use was 34% ever-use and 20% current-use. Most had seen cigarette (91%) and nicotine vaping (80%) product promotions in the past 30 days. A majority reported exposure at point-of-sale and on major (television and cinema) and social media. In adjusted multivariate models, greater exposure to tobacco product promotions was significantly associated with ever and current smoking and vaping; and among never-users, susceptibility to vaping (all p < .01, effect sizes 1.03-1.05). Family/peer use and attitudes also were significant correlates. CONCLUSIONS: Tobacco product promotions remain ubiquitous and are significantly associated with adolescents' tobacco product use and susceptibility to vape. Peers and family are important social influences and may reflect indirect channels of tobacco marketing. Stricter regulatory restrictions on tobacco marketing to young people are warranted. IMPLICATIONS: This study adds to mounting evidence showing that tobacco marketing remains pervasive and is associated with tobacco use and susceptibility to use. Most youth report seeing cigarette and nicotine vaping product promotions, with notable differences by channel: traditional media predominate for cigarettes and social media/email for e-cigarettes. Greater exposure to tobacco promotions is significantly associated with ever and current smoking and vaping, and among never-users, susceptibility to vaping. The accumulating findings support stricter regulatory restrictions on marketing of tobacco products in media channels accessed by youth.

The Impact of COVID-19 on Smoking Patterns in Pakistan: Findings From a Longitudinal Survey of Smokers.

INTRODUCTION: We investigated the influence of COVID-19 on smoking patterns in Pakistan. METHODS: In a longitudinal survey, we asked cigarette smokers in Pakistan about their smoking behaviors before and since COVID-19. Smokers were recruited before COVID-19 using two-stage random probability sampling. Since COVID-19, three subsequent waves were conducted over the telephone, asking additional questions on social determinants, mental health, and well-being. Based on the first two waves, we estimated the proportion of smokers who stopped, decreased, maintained, or increased smoking. We also explored any factors associated with the change in smoking patterns. In those who stopped smoking soon after COVID-19, we estimated the proportion relapsed in subsequent waves. We estimated all proportions based on complete-case analysis. RESULTS: We recruited 6014 smokers between September 2019 and February 2020; of these, 2087 (2062 reported smoking outcomes) were followed up in May 2020 after COVID-19. Since COVID-19, 14% (290/2062) smokers reported quitting. Among those who continued smoking: 68% (1210/1772) reduced, 14% (239/1772) maintained, and 18% (323/1772) increased cigarette consumption; 37% (351/938) reported at least one quit attempt; 41% (669/1619) were more motivated; while 21% (333/1619) were less motivated to quit. Changes in smoking patterns varied with nicotine dependence, motivation to quit, and financial stability since COVID-19. Among those reporting quitting soon after COVID-19, 39% (81/206) relapsed in the subsequent months (June-July 2020). CONCLUSIONS: There have been significant bidirectional changes in smoking patterns since COVID-19 in Pakistan. Although many people stopped, reduced, or tried quitting smoking, some increased smoking and some relapsed after quitting. IMPLICATIONS: We observed significant and complex changes in people's smoking patterns, which are likely to be attributable to the COVID-19 pandemic and replicated in similar events in the future. Assessing these changes is essential for most low- and middle-income countries like Pakistan, where the vast majority of tobacco users live, but cessation support is still rudimentary. If provided routinely, smoking cessation interventions can potentially support millions of highly motivated individuals in quitting successfully both in general and in global events like COVID-19, in particular.

Healthcare Professionals' Beliefs, Attitudes, Knowledge, and Behavior Around Vaping in Pregnancy and Postpartum: A Qualitative Study.

INTRODUCTION: Finding effective ways to help pregnant women quit smoking and maintain long-term abstinence is a public health priority. Electronic cigarettes (ie, vaping) could be a suitable cessation tool in pregnancy for those who struggle to quit; however, healthcare professionals (HCP) must be informed about these devices to offer appropriate advice. This study used the Capability, Opportunity, Motivation, and Behavior (COM-B) model and Theoretical Domains Framework (TDF) to explore HCP attitudes towards vaping in pregnancy and postpartum; beliefs about the health risks of vaping; perceived barriers and facilitators of vaping in pregnancy; knowledge of current guidelines and policies; and training needs. METHODS: Interviews (n = 60) were conducted with midwives (n = 17), health visitors (n = 10), general practitioners (n = 15) and stop smoking specialists (n = 18) across the United Kingdom. Interview transcriptions were analyzed thematically using the framework approach and the COM-B. RESULTS: Discussing vaping as a tool for quitting smoking in pregnancy was prevented by a lack of capability (limited knowledge of vaping, lack of training in smoking cessation); lack of opportunity (restricted by organizational policies and guidelines, lack of time and financial issues impacting on training), and negative social influences (sensationalist media and stigma associated with vaping in pregnancy); and lack of motivation (fear of future litigation and comebacks should adverse effects from vaping arise). CONCLUSIONS: Factors related to capability, opportunity, and motivation were identified that influence HCPs attitudes and behaviors towards vaping in pregnancy. Gaps in knowledge and training needs were identified, which could inform the development of targeted vaping training. IMPLICATIONS: Vaping could be suitable in pregnancy for those struggling to quit smoking. However, HCPs must be informed about these devices to offer appropriate advice. These data extend our knowledge of factors influencing HCP attitudes and behaviors towards vaping in pregnancy. Generally, vaping was perceived as safer than cigarettes, but a perceived lack of evidence, health and safety risks, dependency, and regulation issues were concerning. Considering our findings, greater efforts are needed to ensure HCPs are sufficiently informed about vaping and guidelines available. More importance should be placed on training for all HCPs who have contact with pregnant women.

The effect of SLC6A3 variable number of tandem repeats and methylation levels on individual susceptibility to start tobacco smoking and on the ability of smokers to quit smoking.

OBJECTIVE: Nicotine acts through the dopamine pathway in the brain affecting reward processing through cigarette consumption. Thus, both genetic and epigenetic factors related to dopamine metabolism may influence individual's smoking behavior. MATERIALS AND METHODS: We studied variations of two variable numbers of tandem repeats (VNTRs), 40 and 30 bp in length, in SLC6A3 gene together with six DNA methylation sites located in a first intron of the gene in relation to several smoking-related phenotypes in a study population consisting of 1230 Whites of Russian origin. RESULTS: Both the 5R allele of 30 bp VNTR and the 9R allele of 40 bp VNTR in SLC6A3 were associated with a reduced risk to tobacco smoking [odds ratio (OR) 0.53, 95% confidence interval (CI) 0.37-0.75; OR 0.62, 95% CI 0.43-0.88]. Although the carriers of 9R allele also had high Fagerström test for nicotine dependence scores (OR 1.65, 95% CI 1.04-2.60), they were still more likely to succeed in smoking cessation (OR 0.59, 95% CI 0.40-0.88). Also, current smokers had more than 2.5-fold likelihood to have increased SLC6A3 methylation levels than former smokers (OR 2.72, 95% CI 1.63-4.53). CONCLUSION: The SLC6A3 5R of 30 bp and 9R of 40 bp VNTR variants may lead to a reduced risk to start smoking through decreased dopamine availability, and can also affect the success in subsequent smoking cessation attempts. Moreover, the elevated mean methylation values in the first intron of SLC6A3 may be related to nicotine dependence via a more active dopamine transporter.

Determining factors related to poor quality of life in patients with axial spondyloarthritis: results from the British Society for Rheumatology Biologics Register (BSRBR-AS).

OBJECTIVE: To determine modifiable factors associated with poor quality of life (QoL) in patients with axial spondyloarthritis (axSpA). METHODS: Analysis of data from the British Society for Rheumatology Biologics Register in Ankylosing Spondylitis (BSRBR-AS) and validation of a previous model using data from 1810 patients with axSpA recruited during 2012-2017. Data collected included clinical and patient-reported measures. QoL was assessed using the Ankylosing Spondylitis Quality of Life (ASQoL) measure. Linear regression models predicting ASQoL scores were used first to validate a previous model from a national study, to extend this with additional information available in BSRBR-AS and finally to identify a 'de novo' model from BSRBR-AS of which factors impact on poor QoL. RESULTS: Four out of five factors included in a previous model of poor QoL in patients with axSpA were confirmed: Bath Ankylosing Spondylitis Disease Activity Index and Bath Ankylosing Spondylitis Functional Index, fatigue and widespread pain, although the performance of the model was improved by the addition of measures of mood and sleep disturbance. In a de novo model in BSRBR-AS, there were six factors (other than disease activity and function) that predicted ASQoL: depression (ß=0.16), sleep disturbance (ß=0.08), activity impairment (ß=0.04), fibromyalgia (Symptom Severity Scale (ß=0.24) and Widespread Pain Index (ß=0.10)) and tobacco smoking (ß=0.66). CONCLUSION: This study confirms that poor QoL in patients with axSpA, in addition to high disease activity and poor function, is independently influenced by sleep disturbance, mood and widespread pain. These additional factors are not considered targets for treatment in current European League Against Rheumatism (EULAR) guidelines for managing the condition.

Neural Basis of Smoking-Related Difficulties in Emotion Regulation.

BACKGROUND: Negative emotional states contribute to cigarette smoking, and difficulties in regulating these states can hinder smoking cessation. Understanding the neural bases of these difficulties in smokers may facilitate development of novel therapies for Tobacco Use Disorder. METHODS: Thirty-seven participants (18 smokers, 19 nonsmokers; 16-21 years old) completed the Difficulties in Emotion Regulation Scale (DERS), which is comprised of 6 subscales (lack of emotional clarity, lack of emotional awareness, limited access to emotion regulation strategies, nonacceptance of emotional responses, difficulties engaging in goal-directed behaviors, and impulse control difficulties) that combine to provide a total score. Participants also underwent functional magnetic resonance imaging to determine resting-state functional connectivity of the amygdala. Separate ANOVAs were used to determine group differences in self-reports on the DERS. Voxel-wise linear mixed models were performed to determine whether group influenced relationships between whole-brain functional connectivity of the amygdala and scores on the DERS. RESULTS: Compared with nonsmokers, smokers reported greater difficulties in emotion regulation, denoted by higher total scores on the DERS. Group differences were observed on a subscale of lack of emotional clarity, but no other subscale differences on the DERS were observed. Nonsmokers exhibited a greater negative correlation than smokers between lack of emotional clarity scores and connectivity of the amygdala with the left inferior frontal gyrus. Finally, this amygdala-to-left inferior frontal gyrus connectivity was weaker in smokers than in nonsmokers. CONCLUSIONS: These findings suggest that difficulties in emotion regulation in smokers are at least partially due to lack of emotional clarity. Given the role of the inferior frontal gyrus in understanding emotional states, strengthening connectivity between the amygdala and the inferior frontal gyrus may improve emotional clarity to help smokers regulate their negative emotions, thereby improving their ability to quit smoking.

Effectiveness of Mindfulness-Based Relapse Prevention Program as an Adjunct to the Standard Treatment for Smoking: A Pragmatic Design Pilot Study.

INTRODUCTION: Posttreatment relapse is a major roadblock to stemming the global epidemic of tobacco-related illness. This article presents results from a pilot trial evaluating the feasibility and initial efficacy of Mindfulness-Based Relapse Prevention (MBRP) as an adjunct to standard relapse prevention treatment (ST) for smoking cessation. AIMS AND METHODS: Smokers (n = 86) in the maintenance phase of treatment were randomized to receive either ST plus MBRP (MBRP) (n = 44) or ST alone (ST) (n = 42). Data were collected at baseline and at 4-, 12-, and 24-week follow-up points. We evaluated the feasibility of the protocol with frequency analysis, and the efficacy with both intention to treat and complete case analyses of the effects of MBRP on abstinence. Secondary outcomes included mindfulness, craving, depression, anxiety, and positive/negative affect. RESULTS: High adherence suggested MBRP is acceptable and feasible. Participants in the MBRP group reported increases in mindfulness (M = -7.833, p = .016), and reductions in craving (M = 17.583, p = .01) compared with the ST group. Intention to treat analysis found that, compared with MBRP (36.4%), ST (57.1%) showed trend-level superiority in abstinence at Week 4 (Prevalence Ratio = 0.63, p = .06); however at Week 24, the ST group (14.3%) demonstrated a twofold greater decrease in abstinence, compared with the MBRP group (20.1%) (Prevalence Ratio = 2.25, p = .08). Therefore, the MBRP group maintained a higher abstinence rate for longer. Reported effects were greater in the complete case analysis. CONCLUSIONS: MBRP holds promise for preventing relapse after aided tobacco quit attempts. IMPLICATIONS: Findings suggest that MBRP is acceptable, feasible, and valued by participants. At 24-week follow-up, there was a large effect size and a statistical trend toward fewer MBRP patients relapsing compared with ST patients. MBRP conferred ancillary benefits including reductions in craving and increases in levels of mindfulness. MBRP for tobacco cessation is highly promising and merits further research. TRIAL REGISTRATION: clinicaltrials.gov. IDENTIFIER: NCT02327104.

Class Status and Social Mobility on Tobacco Smoking in Post-Reform China Between 1991 and 2011.

INTRODUCTION: There is growing attention to social mobility's impact on tobacco use, but few studies have differentiated the two conceptually distinct mechanisms through which changes in social class can affect tobacco smoking: the class status effect and the mobility effect. AIMS AND METHODS: I applied Diagonal Reference Modeling to smoking and heavy smoking among respondents of the 1991 China Health and Nutrition Survey who were revisited two decades later in 2011 (n = 3841, 49% male, baseline mean age was 38 years). I divided the sample into six social classes (non-employment, self-employed, owners, workers, farmers, and retirees) and measured social mobility by changes in income and occupational prestige. RESULTS: About 61.7% of men were smokers and those from the classes of workers, owners, and self-employees consumed more cigarettes compared to the unemployed, but women smokers (3.7%) tend to be from the lower classes (unemployed and farmers). Controlling for social class, each 1000 Yuan increase in annual income led to smoking 0.03 more cigarettes (p < .05) and 1% increase (p < .05) in the likelihood of heavy smoking among men, but the income effect is null for women. Upwardly mobile men (a 10-points surge in occupational prestige) smoked like their destination class (weight = 78%), whereas men with downward mobility were more similar to peers in the original class (weight = 60%). CONCLUSIONS: Contrary to the social gradient in smoking in other industrial countries, higher class status and upward mobility are each associated with more smoking among Chinese men, but not among women. IMPLICATIONS: Tobacco control policies should prioritize male smoking at workplaces and the instrumental purposes of using tobacco as gifts and social lubricant. Taxation may counter the surge in smoking brought by individuals' income increase after upward mobility. Caution should be paid to women joining the similar social gradient in smoking as they gain foothold in the labor market.

Comparative Effectiveness of Group-Delivered Acceptance and Commitment Therapy versus Cognitive Behavioral Therapy for Smoking Cessation: A Randomized Controlled Trial.

INTRODUCTION: Preliminary trial data suggest group-delivered acceptance and commitment therapy (ACT) might be effective for smoking cessation. If so, this could offer a viable alternative to mainstream behavioral therapies, such as those grounded in cognitive behavioral therapy (CBT). The goal of the current study was to compare the effectiveness of group-delivered ACT versus group-delivered CBT in a rigorous randomized trial design with long-term follow-up. METHODS: Participants (n = 450) were recruited from the Kaiser Permanente Washington health care system and randomized to either ACT-based group counseling or an attention-matched CBT-based group program. All were prescribed an 8-week course of nicotine patches. The primary outcome was self-reported 30-day point prevalence abstinence at 12 months post-randomization assessed with missing values imputed as smoking. Sensitivity analyses using multiple imputation and complete cases were examined, as were biochemically confirmed and 6-month outcomes. RESULTS: Thirty-day point prevalence abstinence rates at the 12-month follow-up did not differ between study arms in the primary analysis (13.8% ACT vs. 18.1% CBT, adjusted odds ratio = 0.68 [95% CI = 0.35 to 1.27], p = .23) or the sensitivity analyses. CONCLUSIONS: Group-based ACT and CBT had similar long-term quit rates in this methodologically rigorous randomized trial. Group-based ACT is a reasonable alternative to group-based CBT for smoking cessation. IMPLICATIONS: This study compared the effectiveness of group-based ACT with group-based CBT for smoking cessation using a rigorous, large-scale, attention-matched, randomized trial with 1-year follow-up. One-year cessation rates did not differ between group-based ACT and CBT, suggesting ACT-based intervention is a reasonable alternative to CBT-based counseling for smoking cessation. The results add to the nascent but growing literature assessing ACT and other mindfulness-based treatments for smoking cessation.

Decrease in Resting Heart Rate Measured Using Smartphone Apps to Verify Abstinence From Smoking: An Exploratory Study.

INTRODUCTION: Verifying self-reports of smoking abstinence is challenging in studies that involve remote data collection. Resting heart rate (HR) decreases during smoking abstinence. This study assessed whether a decrease in resting HR measured using freely available smartphone apps could potentially be used to verify smoking abstinence. METHODS: This study involved a repeated measures experimental design, with data collection in natural setting. Participants were 18 adult, daily smokers. They recorded resting HR in beats per minute (bpm) using freely available smartphone apps during five timepoints (two in the morning and three postnoon) on each of 3 days. The outcome measure was the mean of the postnoon HR recordings. The experimental condition for each of the 3 days (counterbalanced order) was as follows: (1) smoking as usual, (2) not smoking without nicotine replacement therapy (NRT), or (3) not smoking but using NRT. Abstinence was verified using expired-air carbon monoxide (CO) concentration. RESULTS: Compared with the smoking as usual condition, mean HR was 13.4 bpm lower (95% confidence interval [CI] = 5.4 to 21.4, p = .001) in the not smoking without NRT condition and 10.4 bpm lower (95% CI = 3.1 to 17.8, p = 0.004) in the not smoking with NRT condition. There was no statistically significant difference in HR between the two not smoking conditions (p = .39). Abstinence during not smoking days without and with NRT was CO-verified in 18/18 and in 16/18 cases, respectively. CONCLUSIONS: Self-recording of resting HR in natural setting using smartphone apps shows a reliable decrease in response to smoking abstinence and may provide a basis for remote verification in smoking cessation studies. IMPLICATIONS: Remote verification of self-reported abstinence in smoking cessation studies remains challenging. Smoking abstinence has been shown to decrease resting HR under laboratory conditions. This study demonstrated that self-recording using freely available smartphone apps shows reliable decreases in resting HR during smoking abstinence and may provide a basis for inexpensive remote verification of smoking abstinence.

Smoking Across the Menopausal Transition in a 10-Year Longitudinal Sample: The Role of Sex Hormones and Depressive Symptoms.

INTRODUCTION: Current cigarette smoking rates among older women remain problematic, especially given that this population experiences increased smoking-related health consequences. Despite these increased health concerns, little research to date has explored smoking patterns across the menopausal transition (pre-, early-peri-, late-peri-, and postmenopausal) or the effect of unique factors such as sex hormones and depression during this transition. METHODS: This study used 10 yearly waves of data from the Study of Women's Health Across the Nation, a longitudinal dataset. Data included 1397 women endorsing ever smoking regularly at baseline. Random-effects logistic regression models were used to examine smoking transitions. RESULTS: Although there were no associations between menopausal transition stage and smoking behavior, increased estradiol was associated with an increased likelihood of quitting regular smoking (eg, transitioning from regular smoking to non-regular or no smoking; odds ratio [OR] = 1.28), whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking (eg, transitioning from former or nonregular smoking to regular smoking OR = 2.56). Depression was associated with increased likelihood of continued smoking (OR = 0.97) and relapse (OR = 1.03). CONCLUSIONS: The results emphasize the need to develop interventions to target initiated or continued smoking among women across the menopausal transition and specifically highlight the importance of developing treatments that target depressive symptoms in this population. In addition, although singular hormone measures were associated with smoking behavior, there is a need for future study of dynamic changes in hormones, as well as the impact of progesterone on smoking behaviors across the menopausal transition. IMPLICATIONS: To date, no studies have examined smoking behaviors across the menopausal transition. In this study, although menopausal transition status was not significantly related to transitions in smoking behavior, important relationships between sex hormones and depression were observed. Increased estradiol was associated with an increased likelihood of quitting regular smoking, whereas increased testosterone was associated with an increased likelihood of relapsing to regular smoking behavior. Higher depression scores were related to continued smoking and relapse to regular smoking behavior. These results highlight the need to develop interventions to target smoking cessation among women across the menopausal transition.

Pathways of Nicotine Product Use: A Qualitative Study of Youth and Young Adults in California.

INTRODUCTION: Existing research on youth's adoption of alternative nicotine delivery systems (ANDS) has focused on identifying pathways of nicotine product use, specifically examining whether vaping encourages progression to smoking. Few studies have considered other pathways of initiation. Qualitative studies suggest that meanings of vaping vary significantly, suggestive of the need for a more nuanced understanding of the role of vaping for youth with different pathways into vaping and smoking. METHODS: We conducted in-depth qualitative interviews with 49 Californian youth between 15 and 25 years old who reported ever vaping nicotine to gain a deeper understanding of their initiation pathways of vaping and smoking, paying special attention to youth's experiences and reasons for ANDS initiation and use. Categorizing participants into initiation pathways by self-reported use and age of initiation of ANDS and cigarettes, we then compared the meaning and role of vaping across three distinct pathways of use: (1) smoking to vaping, (2) vaping to smoking, and (3) vaping only. RESULTS: The most common pathway reported was smoking to vaping (74%), eight participants began vaping before smoking, and five participants reported only vaping but never smoking. Analysis of participants' narratives emphasized that youth in our study, regardless of initiation pathway, were generally aware of the health consequences of smoking and negotiated their use of nicotine products considering relative risks. CONCLUSION: Findings from this study suggest that ANDS serve as a transitional tool for youth who are keenly aware of the health consequences of smoking, thus challenging conventional discourses about ANDS as a threat to youth's health. IMPLICATIONS: This qualitative study queries concerns about the potential of alternative nicotine delivery systems (ANDS) to serve as a gateway into cigarette smoking for youth and young adults. Findings suggest that most of the youth participants discussed and considered relative risks in their pathways of initiation, highlighting the need to acknowledge harm reduction in constructing public health messaging and policies for smoking cessation.

Smoking Decisions: Altered Reinforcement Learning Signals Induced by Nicotine State.

INTRODUCTION: Alterations in dopamine signaling play a key role in reinforcement learning and nicotine addiction, but the relationship between these two processes has not been well characterized. We investigated this relationship in young adult smokers using a combination of behavioral and computational measures of reinforcement learning. METHODS: We asked moderately dependent smokers to engage in a reinforcement learning task three times: smoking as usual, smoking abstinence, and cigarette consumption. Participants' trial-to-trial training choices were modeled using a reinforcement learning model that calculates separate learning rates associated with positive and negative prediction errors. RESULTS: We found that learning from positive prediction error signals is reduced during smoking abstinence and enhanced following cigarette consumption. By contrast, learning from negative prediction error signals was enhanced during smoking abstinence and reduced following cigarette consumption. Finally, when tested with novel pairs of stimuli, participants were relatively better at selecting the positive feedback predicting stimuli than avoiding the negative feedback predicting stimuli during the smoking as usual session, a pattern that reversed following cigarette consumption. CONCLUSIONS: These findings provide a specific computational account of altered reinforcement learning induced by smoking state (abstinence and consumption) and may represent a unique target for treatment of nicotine addiction. IMPLICATIONS: This study illustrates the potential of computational psychiatry for understanding reinforcement learning deficits associated with substance use disorders in general and nicotine addiction in particular. We found that learning from positive prediction error signals is reduced during smoking abstinence and enhanced following cigarette consumption. By contrast, learning from negative prediction error signals was enhanced during smoking abstinence and reduced following cigarette consumption. By highlighting important computational differences between three states of smoking, these findings hold out promise for integrating experimental, computational, and theoretical analyses of decision-making function together with research on addiction-related disorders.

Web-Based Contingency Management for Adolescent Tobacco Smokers: A Clinical Trial.

INTRODUCTION: Adolescence is a critical time when the majority of tobacco users initiate smoking. Contingency management for adolescent smoking cessation has shown promise in previous studies, but efficacy following removal of contingencies is not well understood. This study examined a remote form of contingency management among non-treatment-seeking adolescent smokers. METHODS: Participants (N = 127) submitted breath carbon monoxide (CO) three times daily throughout a 42-day program. For this randomized trial, participants in the active condition (n = 63) were reinforced for providing CO measurements on schedule and below a set criterion, whereas those in the control condition (n = 64) were reinforced for providing CO measurements on schedule. Self-reported smoking and urinary cotinine levels were collected at several timepoints. RESULTS: Active condition showed greater within-group reductions in CO levels relative to control condition, but not at 3- or 6-month follow-up. Active condition reported significantly less smoking during treatment compared to control condition, but not at follow-up. There were no significant differences for urinary cotinine. Overall treatment adherence was low, with only 37% and 51% of possible CO samples being submitted among active and control, respectively. Poor treatment adherence may explain the disparity between CO and cotinine results, and poor follow-up treatment efficacy. CONCLUSIONS: This study replicates feasibility of a remote form of contingency management for adolescent smoking. CO results suggest active condition reduced smoking within group, but treatment adherence and posttreatment efficacy was poor. Future research should focus on increasing adherence for this type of program among adolescent smokers. IMPLICATIONS: This study demonstrates feasibility of a remote form of contingency management therapy for smoking cessation among adolescents, while providing posttreatment efficacy data. Within-group efficacy of this form of treatment is suggested, but treatment adherence and follow-up efficacy were poor. This study underscores the need for further development of contingency management therapy for adolescent smoking cessation, which emphasizes better treatment adherence and posttreatment efficacy.