Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products.

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

Examining Age as a Potential Moderator of Response to Reduced Nicotine Content Cigarettes in Vulnerable Populations.

INTRODUCTION: Young adults (aged 18-24 years) have a higher smoking prevalence than younger and older age groups and young adulthood is an important developmental period during which long-term behavior patterns like cigarette smoking are established. The aim of the current study was to examine how young adult smokers with additional vulnerabilities to smoking respond to reduced nicotine content cigarettes. METHODS: This is a secondary analysis of a double-blind, within-subject experiment conducted with 169 cigarette smokers recruited from populations with comorbid psychiatric conditions or socioeconomic disadvantage assessing acute effects of research cigarettes varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg/g). Participants were dichotomized by chronological age (18-24 vs. ≥25 years). Across 14 laboratory sessions effects of nicotine content were examined on measures of relative reinforcing efficacy (Cigarette Purchase Task [CPT] and Concurrent Choice testing), subjective effects, craving/withdrawal, and smoking topography. Repeated measures analysis of variances were used to examine potential moderating effects of age. RESULTS: Young adults exhibited lower demand for reduced nicotine content cigarettes than older adults across three of five CPT indices (ps < .05). No differences by age were observed on other measures of reinforcing efficacy, subjective effects, craving/withdrawal, or smoking topography where effects generally decreased as an orderly function of decreasing nicotine content (ps <.05). CONCLUSION: Overall, these findings suggest that reducing the nicotine content of cigarettes would decrease the addiction potential of cigarette smoking in young adult smokers as much or perhaps more than older adult smokers from populations at increased vulnerability to smoking, addiction, and smoking-related health consequences. IMPLICATIONS: Reducing the nicotine content in cigarettes to lower addiction potential of smoking has been proposed as a means to improve overall population health. It is imperative to examine how young adults may respond to a nicotine reduction policy. We saw minimal evidence that age moderates acute response and where there was evidence it was in the direction of reduced nicotine content cigarettes having less addictive potential among young versus older adults (eg, steeper decreases in demand for very low nicotine content cigarettes among young versus older adults). Overall, a nicotine reduction policy has the potential to reduce smoking across age groups.

Response to reduced nicotine content cigarettes among smokers differing in tobacco dependence severity.

This study examines whether tobacco dependence severity moderates the acute effects of reducing nicotine content in cigarettes on the addiction potential of smoking, craving/withdrawal, or smoking topography. Participants (N = 169) were daily smokers with mild, moderate, or high tobacco-dependence severity using the Heaviness of Smoking Index. Following brief abstinence, participants smoked research cigarettes varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg nicotine/g tobacco) in a within-subject design. Results were analyzed using repeated measures analysis of co-variance. No main effects of dependence severity or interactions with nicotine dose were noted in relative reinforcing effects in concurrent choice testing or subjective effects on the modified Cigarette Evaluation Questionnaire. Demand for smoking in the Cigarette Purchase Task was greater among more dependent smokers, but reducing nicotine content decreased demand independent of dependence severity. Dependence severity did not significantly alter response to reduced nicotine content cigarettes on the Minnesota Tobacco Withdrawal Scale nor Questionnaire of Smoking Urges-brief (QSU) Factor-2 scale; dependence severity and dose interacted significantly on the QSU-brief Factor-1 scale, with reductions dependent on dose among highly but not mildly or moderately dependent smokers. Dependence severity and dose interacted significantly on only one of six measures of smoking topography (i.e., maximum flow rate), which increased as dose increased among mildly and moderately but not highly dependent smokers. These results suggest that dependence severity has no moderating influence on the ability of reduced nicotine content cigarettes to lower the addiction potential of smoking, and minimal effects on relief from craving/withdrawal or smoking topography.

E-cigarette awareness, perceived harmfulness, and ever use among U.S. adults.

The overarching aims of this study are to (a) estimate and update knowledge on rates and predictors of awareness, perceived harmfulness, and ever use of e-cigarettes among U.S. adults and (b) to utilize that information to identify risk-factor profiles associated with ever use. Data were collected from the 2015 Health Information National Trends Survey (N=3738). Logistic regression was used to explore relationships between sociodemographics (gender, age, race/ethnicity, sexual orientation, educational attainment, income, and census region), current use of other tobacco products (conventional cigarettes, cigars, and smokeless tobacco), ever use of alternative products (hookah, pipes, roll-your-own cigarettes, and snus) and e-cigarette awareness, perceived harm, and ever use. Classification and regression tree (CART) modeling was used to examine risk-factor profiles of e-cigarette ever use. Results showed that most respondents were aware of e-cigarettes (83.6%) and perceived them to be not at all or moderately harmful (54.7%). Prevalence of e-cigarette ever use was 22.4%. Current cigarette smoking and ever use of alternative tobacco products were powerful predictors of use. Other predictors of use of e-cigarettes were age, race/ethnicity, and educational attainment. Awareness and perceived harm were significant predictors among particular smoker subgroups. Fifteen risk profiles were identified across which prevalence of e-cigarette use varied from 6 to 94%. These results underscore the need to continue monitoring patterns of e-cigarette use. They also provide new knowledge regarding risk-profiles associated with striking differences in prevalence of e-cigarette use that have the potential to be helpful when considering the need for or impact of e-cigarette regulatory policies.

Use of higher-nicotine/tar-yield (regular full-flavor) cigarettes is associated with nicotine dependence and smoking during pregnancy among U.S. women.

The present study examined full-flavor cigarette use among women of reproductive age to assess whether use is associated with greater nicotine dependence and smoking during pregnancy. We used data from the National Survey on Drug Use and Health (2005-2014). Consecutive years were combined to assure sufficient numbers of pregnant women. We examined whether use of full-flavor cigarettes was associated with greater odds of nicotine dependence using the Fagerstrom Test for Nicotine Dependence and Nicotine Dependence Syndrome Scale (NDSS), controlling for other smoking characteristics. We next compared prevalence of smoking and use of full-flavor versus lower-yield cigarettes among non-pregnant versus pregnant women and across trimesters. Lastly, we examined whether pregnancy was associated with greater odds of using full-flavor cigarettes after controlling for potential confounders. Use of full-flavor cigarettes was associated with greater adjusted odds of nicotine dependence compared to lower yields among non-pregnant (Fagerstrom: 2.50, 95% CI: 2.32,2.70; NDSS: 1.75, 95% CI: 1.62,1.88) and pregnant (Fagerstrom: 1.53, 95% CI: 1.13,2.05; NDSS: 1.53, 95% CI: 1.12,2.10) smokers. As smoking prevalence decreased among pregnant compared to non-pregnant women (14.31±0.55% versus 22.73±0.17%), prevalence of using full-flavor cigarettes increased (54.82±1.63% versus 38.86±0.35%). Similarly, as smoking prevalence decreased from 1st to 3rd trimester (19.65±1.2%, 12.50±0.84%, 11.3±0.83%), prevalence of using full-flavor cigarettes increased (53.12±2.53%, 50.57+2.92%, 63.63±3.19%). Overall, pregnancy was associated with 1.43 (95% CI: 1.22, 1.68) greater adjusted odds of full-flavor cigarette use. These results indicate that users of full-flavor cigarettes have greater nicotine-dependence risk and lower likelihood of quitting smoking during pregnancy, relationships with potential for serious adverse maternal-infant health impacts.

Socioeconomic Disadvantage and Other Risk Factors for Using Higher-Nicotine/Tar-Yield (Regular Full-Flavor) Cigarettes.

INTRODUCTION: Use of machine-estimated higher nicotine/tar yield (regular full-flavor) cigarettes is associated with increased risk of nicotine dependence. The present study examined risk factors for using full-flavor versus other cigarette types, including socioeconomic disadvantage and other risk factors for tobacco use or tobacco-related adverse health impacts. Associations between use of full-flavor cigarettes and risk of nicotine dependence were also examined. METHODS: Data were obtained from nationally representative samples of adult cigarette smokers from the US National Survey on Drug Use and Health. Logistic regression and classification and regression tree modeling were used to examine associations between use of full-flavor cigarettes and educational attainment, poverty, race/ethnicity, age, sex, mental illness, alcohol abuse/dependence, and illicit drug abuse/dependence. Logistic regression was used to examine risk for nicotine dependence. RESULTS: Each of these risk factors except alcohol abuse/dependence independently predicted increased odds of using full-flavor cigarettes (p < .001), with lower educational attainment the strongest predictor, followed by poverty, male sex, younger age, minority race/ethnicity, mental illness, and drug abuse/dependence, respectively. Use of full-flavor cigarettes was associated with increased odds of nicotine dependence within each of these risk factor groupings (p < .01). Cart modeling identified how prevalence of full-flavor cigarette use can vary from a low of 25% to a high of 66% corresponding to differing combinations of these independent risk factors. CONCLUSIONS: Use of full-flavor cigarettes is overrepresented in socioeconomically disadvantaged and other vulnerable populations, and associated with increased risk of nicotine dependence. Greater regulation of this cigarette type may be warranted. IMPLICATIONS: Greater regulation of commercially available Regular Full-Flavor Cigarettes may be warranted. Use of this type of cigarette is overrepresented in socioeconomically disadvantaged and other vulnerable populations and associated with increased risk for nicotine dependence.

Development of a Self-Report Measure of Reward Sensitivity:A Test in Current and Former Smokers.

INTRODUCTION: Tobacco use or abstinence may increase or decrease reward sensitivity. Most existing measures of reward sensitivity were developed decades ago, and few have undergone extensive psychometric testing. METHODS: We developed a 58-item survey of the anticipated enjoyment from, wanting for, and frequency of common rewards (the Rewarding Events Inventory-REI). The current analysis focuses on ratings of anticipated enjoyment. The first validation study recruited current and former smokers from Internet sites. The second study recruited smokers who wished to quit and monetarily reinforced them to stay abstinent in a laboratory study and a comparison group of former smokers. In both studies, participants completed the inventory on two occasions, 3-7 days apart. They also completed four anhedonia scales and a behavioral test of reduced reward sensitivity. RESULTS: Half of the enjoyment ratings loaded on four factors: socializing, active hobbies, passive hobbies, and sex/drug use. Cronbach's alpha coefficients were all ≥0.73 for overall mean and factor scores. Test-retest correlations were all ≥0.83. Correlations of the overall and factor scores with frequency of rewards and anhedonia scales were 0.19-0.53, except for the sex/drugs factor. The scores did not correlate with behavioral tests of reward and did not differ between current and former smokers. Lower overall mean enjoyment score predicted a shorter time to relapse. DISCUSSION: Internal reliability and test-retest reliability of the enjoyment outcomes of the REI are excellent, and construct and predictive validity are modest but promising. The REI is comprehensive and up-to-date, yet is short enough to use on repeated occasions. Replication tests, especially predictive validity tests, are needed. IMPLICATIONS: Both use of and abstinence from nicotine appear to increase or decrease how rewarding nondrug rewards are; however, self-report scales to test this have limitations. Our inventory of enjoyment from 58 rewards appears to be reliable and valid as well as comprehensive and up-to-date, yet is short enough to use on repeated occasions. Replication tests, especially of the predictive validity of our scale, are needed.

E-cigarette use among women of reproductive age: Impulsivity, cigarette smoking status, and other risk factors.

INTRODUCTION: The study aim was to examine impulsivity and other risk factors for e-cigarette use among women of reproductive age comparing current daily cigarette smokers to never cigarette smokers. Women of reproductive age are of special interest because of the additional risk that tobacco and nicotine use represents should they become pregnant. METHOD: Survey data were collected anonymously online using Amazon Mechanical Turk in 2014. Participants were 800 women ages 24-44years from the US. Half (n=400) reported current, daily smoking and half (n=400) reported smoking <100 cigarettes lifetime. Participants completed questionnaires regarding sociodemographics, tobacco/nicotine use, and impulsivity (i.e., delay discounting & Barratt Impulsiveness Scale). Predictors of smoking and e-cigarette use were examined using logistic regression. RESULTS: Daily cigarette smoking was associated with greater impulsivity, lower education, past illegal drug use, and White race/ethnicity. E-cigarette use in the overall sample was associated with being a cigarette smoker and greater education. E-cigarette use among current smokers was associated with increased nicotine dependence and quitting smoking; among never smokers it was associated with greater impulsivity and illegal drug use. E-cigarette use was associated with hookah use, and for never smokers only with use of cigars and other nicotine products. CONCLUSIONS: E-cigarette use among women of reproductive age varies by smoking status, with use among current smokers reflecting attempts to quit smoking whereas among non-smokers use may be a marker of a more impulsive repertoire that includes greater use of alternative tobacco products and illegal drugs.

Characterizing the intersection of Co-occurring risk factors for illicit drug abuse and dependence in a U.S. nationally representative sample.

Few studies have attempted to characterize how co-occurring risk factors for substance use disorders intersect. A recent study examined this question regarding cigarette smoking and demonstrated that co-occurring risk factors generally act independently. The present study examines whether that same pattern of independent intersection of risk factors extends to illicit drug abuse/dependence using a U.S. nationally representative sample (National Survey on Drug Use and Health, 2011-2013). Logistic regression and classification and regression tree (CART) modeling were used to examine risk of past-year drug abuse/dependence associated with a well-established set of risk factors for substance use (age, gender, race/ethnicity, education, poverty, smoking status, alcohol abuse/dependence, mental illness). Each of these risk factors was associated with significant increases in the odds of drug abuse/dependence in univariate logistic regressions. Each remained significant in a multivariate model examining all eight risk factors simultaneously. CART modeling of these 8 risk factors identified subpopulation risk profiles wherein drug abuse/dependence prevalence varied from <1% to >80% corresponding to differing combinations of risk factors present. Alcohol abuse/dependence and cigarette smoking had the strongest associations with drug abuse/dependence risk. These results demonstrate that co-occurring risk factors for illicit drug/abuse dependence generally intersect in the same independent manner as risk factors for cigarette smoking, underscoring further fundamental commonalities across these different types of substance use disorders. These results also underscore the fundamental importance of differences in the presence of co-occurring risk factors when considering the often strikingly different prevalence rates of illicit drug abuse/dependence in U.S. population subgroups.

Some context for understanding the place of the general educational development degree in the relationship between educational attainment and smoking prevalence.

INTRODUCTION: Individuals with a General Educational Development (GED) degree have the highest smoking prevalence of any education level, including high school dropouts without a GED. Yet little research has been reported providing a context for understanding the exception that the GED represents in the otherwise graded inverse relationship between educational attainment and smoking prevalence. We investigated whether the GED may be associated with a general riskier profile that includes but is not limited to increased smoking prevalence. METHOD: Data were obtained from three years (2011-2013) of the National Survey on Drug Use and Health ([NSDUH], N=55,940]). Prevalence of risky repertoire indicators (e.g., ever arrested, seldom/never wears a seatbelt), indicators of social instability (e.g., frequent relocations), and risky demographic characteristics (e.g., male gender) were compared among high school dropouts, GED holders, and high school graduates using Rao-Scott chi square goodness-of-fit tests and multiple logistic regression. RESULTS: Those with GEDs differed significantly between both high school dropouts and high school graduates across 19 of 27 (70.4%) risk indicators. Controlling for risky profile characteristics accounted for a significant but limited (25-30%) proportion of the variance in smoking prevalence across these three education levels. CONCLUSION: GED holders exhibit a broad high-risk profile of which smoking is just one component. Future research evaluating additional risk indicators and mechanisms that may underpin this generalized risky repertoire are likely needed for a more complete understanding of GED's place in the important relationship between educational attainment and smoking prevalence.

Co-occurring risk factors for current cigarette smoking in a U.S. nationally representative sample.

INTRODUCTION: Relatively little has been reported characterizing cumulative risk associated with co-occurring risk factors for cigarette smoking. The purpose of the present study was to address that knowledge gap in a U.S. nationally representative sample. METHODS: Data were obtained from 114,426 adults (≥18years) in the U.S. National Survey on Drug Use and Health (years 2011-13). Multiple logistic regression and classification and regression tree (CART) modeling were used to examine risk of current smoking associated with eight co-occurring risk factors (age, gender, race/ethnicity, educational attainment, poverty, drug abuse/dependence, alcohol abuse/dependence, mental illness). RESULTS: Each of these eight risk factors was independently associated with significant increases in the odds of smoking when concurrently present in a multiple logistic regression model. Effects of risk-factor combinations were typically summative. Exceptions to that pattern were in the direction of less-than-summative effects when one of the combined risk factors was associated with generally high or low rates of smoking (e.g., drug abuse/dependence, age ≥65). CART modeling identified subpopulation risk profiles wherein smoking prevalence varied from a low of 11% to a high of 74% depending on particular risk factor combinations. Being a college graduate was the strongest independent predictor of smoking status, classifying 30% of the adult population. CONCLUSIONS: These results offer strong evidence that the effects associated with common risk factors for cigarette smoking are independent, cumulative, and generally summative. The results also offer potentially useful insights into national population risk profiles around which U.S. tobacco policies can be developed or refined.

Examination of a mouthpiece-based topography device for assessing relative reinforcing effects of e-cigarettes: A preliminary study.

The assessment of vaping topography has helped to identify characteristics associated with distinct vaping patterns. Available puff topography devices do not alter the subjective effects of vaping. However, one central construct related to drug abuse, unexplored in prior studies, is whether relative reinforcing effects (RRE) of vaping change when using a topography device. We examined the RRE of vaping when individuals vape through an e-cigarette with a mouthpiece topography device attached versus their own e-cigarette. Associations of demand indices for participants' own e-cigarette and for a research e-cigarette with a topography device were also explored. Forty-three e-cigarette users attended 1 experimental session where they completed 2 purchase tasks in different units of consumption, ml and puffs, with their preferred e-cigarette and with an e-cigarette with a mouthpiece. Puff topography was measured in the mouthpiece condition. All four purchase tasks showed the predicted inverse relationship between purchase and price. No differences in most demand indices were observed between both e-cigarettes, except for breakpoint (lowest price that suppresses consumption) and Omax (maximum expenditure) in ml units which both decreased when participants vaped through the mouthpiece device. Demand indices in ml units were more strongly associated. Data from the purchase tasks suggests that the presence of a mouthpiece topography device does not influence the RRE of vaping among e-cigarette users. Demand for e-cigarettes seems more consistent in ml units. Our results further evidence that mouthpiece topography devices represent a valid and reliable instrument to study RRE of e-cigarettes and, by extension, abuse liability. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Changes in Cigarette Consumption With Reduced Nicotine Content Cigarettes Among Smokers With Psychiatric Conditions or Socioeconomic Disadvantage: 3 Randomized Clinical Trials.

Importance: This study is part of a programmatic effort evaluating the effects of reducing nicotine content of cigarettes to minimally addictive levels. Objective: To examine whether very low-nicotine-content (VLNC) cigarettes decrease smoking rates and dependence severity among smokers with psychiatric disorders or socioeconomic disadvantage. Design, Setting, and Participants: These 3 randomized clinical trials were performed at the University of Vermont, Brown University, and Johns Hopkins University between October 2016 and September 2019. Participants received 12 weeks of exposure to study cigarettes with nicotine content ranging from levels representative of commercial cigarettes (15.8 mg nicotine/g tobacco) to less than a hypothesized addiction threshold (2.4 mg/g and 0.4 mg/g). Daily smokers from 3 at-risk populations participated: individuals with affective disorders, exemplifying smokers with mental illness; individuals with opioid use disorder, exemplifying smokers with substance use disorders; and women with high school educations or less, exemplifying smokers with socioeconomic disadvantage. Data were analyzed from September 2019 to July 2020. Interventions: Random assignment to 1 of 3 study cigarettes provided weekly at no cost for 12 weeks. Main Outcomes and Measures: The primary outcome was between-group differences in mean total cigarettes smoked daily (CPD) during week 12; secondary outcomes included CPD for study and nonstudy cigarettes and dependence severity across weeks analyzed using analysis of covariance, random coefficients growth modeling, or repeated measures analysis of variance. Results: A total of 775 participants were included (mean [SD] age, 35.59 [11.05] years; 551 [71.10%] women [owing to 1 population being exclusively women]); participants smoked a mean (SD) of 17.79 (9.18) CPD at study intake. A total of 286 participants were randomized to 0.4 mg/g, 235 participants were randomized to 2.4 mg/g, and 254 participants were randomized to 15.8 mg/g. Participants randomized to VLNC cigarettes had decreased mean [SEM] total CPD during week 12 across populations (Cohen d = 0.61; P < .001). At week 12, mean (SEM) CPD decreased to 17.96 (0.98) CPD in the 0.4 mg/g group and to 19.53 (1.07) CPD in the 2.4 mg/g group, both of which were significantly different from the 15.8 mg/g group (25.08 [1.08] CPD at week 12) but not each other (0.4 mg/g adjusted mean difference: -7.54 [95%CI, -9.51 to -5.57]; 2.4 mg/g adjusted mean difference: -5.34 [95% CI, 7.41 to -3.26]). Several secondary outcomes differed across populations randomized to VLNCs, including mean total CPD across weeks, with linear trends lower in participants receiving 0.4 mg/g (-0.28 [95%CI, -0.39 to -0.18]; P < .001) and 2.4 mg/g (-0.13 [95%CI, -0.25 to -0.01]; P < .001) doses compared with those receiving the 15.8 mg/g dose (0.30 [95% CI, 0.19 to 0.41]). Fagerström Test of Nicotine Dependence mean total scores were significantly lower in participants who received VLNCs (Cohen d = 0.12; P < .001), with those who received the 0.4 mg/g dose (mean [SD] score, 3.99 [0.06]; P < .001 vs 15.8 mg/g) or 2.4 mg/g dose (mean [SD] score, 4.07 [0.06]; P = .01 vs 15.8 mg/g) differing from those who received the 15.8 mg/g dose (mean [SD] score, 4.31 [0.06]) but not from each other. Conclusions and Relevance: These findings demonstrate that decreasing the nicotine content of cigarettes to very low levels reduced smoking rate and nicotine-dependence severity in these high-risk populations, effects that may facilitate successful cessation. Trial Registration: ClinicalTrials.gov Identifiers: NCT02232737, NCT02250664, NCT02250534.

Response to Reduced Nicotine Content in Vulnerable Populations: Effect of Menthol Status.

OBJECTIVES: In this study, we investigated potential effects of being a menthol smoker on response to reduced nicotine content (RNC) cigarettes in smokers especially vulnerable to smoking. METHOD: Participants were 169 smokers (61 menthol and 108 non-menthol smokers) with comorbid mental illness, substance use disorder, or socioeconomic disadvantage. Participants completed a double-blind study assessing addiction potential, withdrawal/craving, and compensatory smoking across 4 research cigarettes varying in nicotine content from very low levels to commercial levels (0.4, 2.4, 5.2, 15.8mg/g of tobacco). Repeated measures analysis of variance was used to examine potential moderating effects of menthol status. RESULTS: Statistically significant effects of nicotine dose were noted across measures, with higher doses producing greater economic demand and relief from withdrawal/craving. The relationships between nicotine dose and response to RNC cigarettes do not differ by menthol status. CONCLUSIONS: Results of this study suggest menthol does not have a differential impact on response to RNC cigarettes across measures of economic demand, withdrawal/craving, or smoking topography. These results suggest that any potential beneficial effects of RNC cigarettes should extend to menthol smokers including those especially vulnerable to smoking.

Smoking prevalence and trends among a U.S. national sample of women of reproductive age in rural versus urban settings.

U.S. smoking prevalence is declining at a slower rate in rural than urban settings and contributing to regional health disparities. Cigarette smoking among women of reproductive age is particularly concerning due to the potential for serious maternal and infant adverse health effects should a smoker become pregnant. The aim of the present study was to examine whether this rural-urban disparity impacts women of reproductive age (ages 15-44) including pregnant women. Data came from the ten most recent years of the U.S. National Survey on Drug Use and Health (2007-2016). We estimated prevalence of current smoking and nicotine dependence among women categorized by rural-urban residence, pregnancy status, and trends using chi-square testing and multivariable modeling while adjusting for common risk factors for smoking. Despite overall decreasing trends in smoking prevalence, prevalence was higher among rural than urban women of reproductive age overall (χ2(1) = 579.33, p < .0001) and among non-pregnant (χ2(1) = 578.0, p < .0001) and pregnant (χ2(1) = 79.69, p < .0001) women examined separately. An interaction between residence and pregnancy status showed adjusted odds of smoking among urban pregnant compared to non-pregnant women (AOR = .58, [.53 -.63]) were lower than those among rural pregnant compared to non-pregnant women (AOR = 0.75, [.62 -.92]), consistent with greater pregnancy-related smoking cessation among urban pregnant women. Prevalence of nicotine dependence was also higher in rural than urban smokers overall (χ2(2) = 790.42, p < .0001) and among non-pregnant (χ2(2) = 790.58, p < .0001) and pregnant women examined separately (χ2(2) = 63.69, p < .0001), with no significant changes over time. Associations involving residence and pregnancy status remained significant in models adjusting for covariates (ps < 0.05). Results document greater prevalence of smoking and nicotine dependence and suggest less pregnancy-related quitting among rural compared to urban women, disparities that have potential for direct, multi-generational adverse health impacts.

Response to varying the nicotine content of cigarettes in vulnerable populations: an initial experimental examination of acute effects.

RATIONALE: The purpose of this study was to begin researching the effects of very low nicotine content cigarettes in smokers especially vulnerable to dependence to assess their potential as a less dependence-producing alternative to current commercial cigarettes. METHODS: Participants were 26 adult, daily cigarette smokers from one of three populations: economically disadvantaged women of reproductive age (n = 9), opioid-dependent individuals (n = 11), and individuals with affective disorders (n = 6). Participants completed fourteen 2-4-h experimental sessions in a within-subjects research design. Sessions were conducted following brief smoking abstinence. Four research cigarettes varying in nicotine content (0.4, 2.4, 5.2, and 15.8 mg/g) were studied under double-blind conditions, assessing smoking topography, subjective effects, and relative reinforcing effects of varying doses in concurrent choice tests. Results were collapsed across vulnerable populations and analyzed using repeated measures ANOVA. RESULTS: No significant differences between doses were discernible in smoking topography. All doses were equi-effective at reducing nicotine withdrawal. Ratings of satisfaction from smoking were lower at the 0.4 compared to 15.8 mg/g dose. Participants preferred the 15.8 mg/g dose over the 0.4 and 2.4 but not the 5.2 mg/g doses in concurrent choice testing; no differences between the two lowest doses were noted. CONCLUSIONS: All cigarettes effectively reduced nicotine withdrawal with no differences in smoking topography, suggesting minimal compensatory smoking. Dependence potential was lowest at the 0.4 mg/g dose. These initial results are promising regarding the feasibility of lowering nicotine content in cigarettes to very low levels in vulnerable populations without untoward effects.

Addiction Potential of Cigarettes With Reduced Nicotine Content in Populations With Psychiatric Disorders and Other Vulnerabilities to Tobacco Addiction.

Importance: A national policy is under consideration to reduce the nicotine content of cigarettes to lower nicotine addiction potential in the United States. Objective: To examine how smokers with psychiatric disorders and other vulnerabilities to tobacco addiction respond to cigarettes with reduced nicotine content. Design, Setting, and Participants: A multisite, double-blind, within-participant assessment of acute response to research cigarettes with nicotine content ranging from levels below a hypothesized addiction threshold to those representative of commercial cigarettes (0.4, 2.3, 5.2, and 15.8 mg/g of tobacco) at 3 academic sites included 169 daily smokers from the following 3 vulnerable populations: individuals with affective disorders (n = 56) or opioid dependence (n = 60) and socioeconomically disadvantaged women (n = 53). Data were collected from March 23, 2015, through April 25, 2016. Interventions: After a brief smoking abstinence, participants were exposed to the cigarettes with varying nicotine doses across fourteen 2- to 4-hour outpatient sessions. Main Outcomes and Measures: Addiction potential of the cigarettes was assessed using concurrent choice testing, the Cigarette Purchase Task (CPT), and validated measures of subjective effects, such as the Minnesota Nicotine Withdrawal Scale. Results: Among the 169 daily smokers included in the analysis (120 women [71.0%] and 49 men [29.0%]; mean [SD] age, 35.6 [11.4] years), reducing the nicotine content of cigarettes decreased the relative reinforcing effects of smoking in all 3 populations. Across populations, the 0.4-mg/g dose was chosen significantly less than the 15.8-mg/g dose in concurrent choice testing (mean [SEM] 30% [0.04%] vs 70% [0.04%]; Cohen d = 0.40; P < .001) and generated lower demand in the CPT (α = .027 [95% CI, 0.023-0.031] vs α = .019 [95% CI, 0.016-0.022]; Cohen d = 1.17; P < .001). Preference for higher over lower nicotine content cigarettes could be reversed by increasing the response cost necessary to obtain the higher dose (mean [SEM], 61% [0.02%] vs 39% [0.02%]; Cohen d = 0.40; P < .001). All doses reduced Minnesota Nicotine Withdrawal Scale total scores (range of mean decreases, 0.10-0.50; Cohen d range, 0.21-1.05; P < .001 for all), although duration of withdrawal symptoms was greater at higher doses (η2 = 0.008; dose-by-time interaction, P = .002). Conclusions and Relevance: Reducing the nicotine content of cigarettes may decrease their addiction potential in populations that are highly vulnerable to tobacco addiction. Smokers with psychiatric conditions and socioeconomic disadvantage are more addicted and less likely to quit and experience greater adverse health impacts. Policies to reduce these disparities are needed; reducing the nicotine content in cigarettes should be a policy focus.