Tobacco addiction: implications for treatment and cancer prevention.

The American Society of Clinical Oncology and the National Cancer Institute convened a symposium in June 1996 on tobacco addiction. Additional support for the symposium was provided by the American Medical Women's Association and the American Society of Preventive Oncology. The goals of this conference were to describe the burden and public health consequences of tobacco addiction, to describe the state of science for the treatment of nicotine dependence, and to explore new strategies to increase quit rates and to prevent the uptake of tobacco use. This article summarizes and integrates the meeting presentations on tobacco addiction and includes the topics of smoking prevalence; psychobiologic aspects of nicotine dependence; and implications for disease, treatment, and prevention. Comments on regulatory approaches and national strategies for reducing dependence are also summarized in presentations by Dr. David Kessler, former Food and Drug Administration Commissioner, and Dr. C. Everett Koop, former U.S. Surgeon General.

The effects of smoking on electrocortical arousal in coronary prone (type A) and non-coronary prone (type B) subjects.

Twenty-nine Type A subjects, (greater than 75 percentile on the Jenkins Activity Survey) and 28 Type Bs (less than 25 percentile of the survey) were asked to smoke one cigarette (1.0 mg nicotine, 16 mg tar, 14 mg CO) using a standardized smoking procedure. Significant differences between baseline and smoking conditions were noted in the distribution of electrocortical activity for both groups. In addition, a shift from EEG low frequency high amplitude (alpha) events to high frequency low amplitude activity (beta) was noted for the As, while the Bs showed enhanced very low frequency high amplitude (theta) activity. A striking parallel was observed between the behavioral predisposition of the subject (A/B) and the possible function of the underlying neurological structure mediating the observed EEG changes. It is suggested that the electrocortical changes observed for the As during smoking are mediated by reticular (ARS I) arousal. Enhanced reticular activity may coincide with an increased rate of information processing, attention and vigilance. On the other hand, the electrocortical changes observed for the Type Bs may represent enhanced activity of the limbic system (ARS II) with could coincide with stimulation of the reward/pleasure centers. Smoking may produce a pattern of neurophysiological arousal which parallels the behavioral tempo of the individual. Possible differences in in vivo regulation of nicotine cholinergic binding sites are also discussed.

Behavior therapy and the transdermal nicotine patch: effects on cessation outcome, affect, and coping.

The process and outcome of a smoking cessation program using behavior therapy alone (BT) or behavior therapy plus the nicotine patch (BTP) was studied in 64 participants. Participants quit smoking on a target date after a period of ad libitum smoking, cognitive-behavior therapy preparing them for cessation, and behavioral rehearsal for high-risk situations, including stress management, and coping with negative affect. Abstinence was significantly higher for the BTP group versus the BT group from the end of behavioral treatment (79% vs. 63%) through the 3-month follow-up (p < .01), with the effects weakening at the 6- (p = .06) and 12-month marks (p = 38% vs. 22%). More general distress was observed among BT versus BTP participants (i.e., increased withdrawal, tension, fatigue, and coping frequency with decreased coping effort; coping-to-urge ratio). The coping behavior of the BTP group may have been more effective than that of the BT group, as indicated by their significantly higher level of self-efficacy.

The effects of smoking schedules on cessation outcome: can we improve on common methods of gradual and abrupt nicotine withdrawal?

This study compared the efficacy of 2 traditional methods of smoking cessation, gradual reduction and "cold turkey," with a new approach involving variation in the intercigarette interval. One hundred twenty-eight participants quit smoking on a target date, after a 3-week period of (a) scheduled reduced smoking (progressive increase in the intercigarette interval), (b) nonscheduled reduced smoking (gradual reduction, no specific change in the intercigarette interval), (c) scheduled nonreduced smoking (fixed intercigarette interval, no reductions in frequency), or (c) nonscheduled nonreduced smoking (no change in intercigarette interval or smoking frequency). Participants also received cognitive-behavioral relapse prevention training. Abstinence at 1 year averaged 44%, 18%, 32%, and 22% for the 4 groups, respectively. Overall, the scheduled reduced group performed the best and the nonscheduled reduced group performed the worst. Both scheduled groups performed better than nonscheduled ones. Scheduled reduced smoking was associated with reduced tension, fatigue, urges to smoke, withdrawal symptoms, increased coping effort (ratio of coping behavior to urges), and self-efficacy, suggesting an improved adaptation to nonsmoking and reduced vulnerability to relapse.

Smoking cessation: recent developments in behavioral and pharmacologic interventions.

Smoking kills more than 430,000 people each year in the United States and is currently estimated to be responsible for 30.5% of all cancer-related deaths in our society. The majority of these deaths could be prevented, however, if people refrained from usage of tobacco products. It is, therefore, essential that smoking cessation treatment become an integral component of all types of health care. In order to help clinicians better serve their smoking patients, we present an overview of current trends in the behavioral and pharmacologic treatment of smoking cessation. Although popular with patients, standard self-help interventions provide little clinical utility. A review of the current literature supports the use of behavioral counseling and nicotine replacement therapy as the most efficacious forms of intervention, particularly when combined. Recent trends in cessation research have also included nonnicotine medications, such as antidepressants, anxiolytics, and nicotine antagonists. Although there is insufficient evidence to mandate inclusion of most of these medications in standard smoking cessation treatment at this time, preliminary studies have not ruled out their potential effectiveness.

Nicotine regulation among heavy and light smokers in a non-stressful environment.

The purpose of this study was to assess nicotine regulation among "heavy" and "light" smokers. Previous studies supporting the nicotine regulation model of smoking behavior have suggested that smokers compensate for a reduction in the amount of nicotine available in their cigarette by altering smoking frequency, puff volume, or other aspects of smoking topography. However, little is known about a smoker's decision to smoke a specific cigarette, and the concurrent changes in their blood nicotine. Manipulation of nicotine levels in the blood could play a critical role in smoking maintenance, by regulating the extent and quality of the CNS effects of smoking. In this study, 24 heavy and light smokers (cotinine above or below 260 ng/ml) smoked high- (1.0 mg) or low- (0.5 mg) dose nicotine cigarettes while watching non-stressful movies. Blood nicotine was assessed before and after smoking a preload and free operant cigarette. The results showed that blood nicotine levels after smoking the free operant cigarette were significantly more consistent (lower standard error) for the heavy smokers, following a low dose, as opposed to a high-dose preload. Light smokers showed a non-significant trend towards being more consistent when the high-dose nicotine preload was used. This suggests that heavy smokers may have maximized their dose of nicotine whenever available nicotine was in relatively short supply (low dose condition). However, light smokers may have minimized their exposure when available nicotine was relatively more plentiful (high dose condition).

The effects of smoking on the mood, cardiovascular and adrenergic reactivity of heavy and light smokers in a non-stressful environment.

Following a period of overnight deprivation, 58 smokers participated in a 90-min laboratory assessment in which they viewed a non-stressful movie and smoked two 0.5-mg nicotine-containing cigarettes. The first cigarette was given to all subjects following 25 min of adaptation and baseline. The next cigarette was provided at their request, which occurred 9-12 min later. "Heavy" and "light" smokers were grouped according to their average morning cotinine values, which fell above or below 250 ng/ml, respectively. The results showed that, relative to their baseline, heavy and light smokers experienced about the same level of post-smoking change in blood nicotine, heart rate and blood pressure. However, heavy smokers showed a significantly greater delta from baseline in post-smoking measures of epinephrine, norepinephrine, tension reduction and increase in vigor enhancement. A strong and consistent correlation was observed between post-smoking increases in epinephrine, tension reduction and increased vigor.

An assessment of chronic pain behavior in a structured interview.

The current study evaluated the effects of several situational contexts on the behavior of 25 chronic pain patients. Subjects participated in a 20-minute interview in which questions relevant to both pain and non-pain related experiences were asked. Another part of the interview involved a behavioral task in which the patient was asked to walk, bend and pick up a small object. Target behaviors were measured throughout the interview and included gestures of pain, grimacing, touching, smiles, laughter, changing the topic of conversation, ratings of affect, fluency and loudness, and the duration of eye contact and speech. The results showed a clear differentiation between the frequency of gestures, touching and grimacing between the pain and non-pain events. Behavior during the motor task was similar to the pain situations. Ratings of affect, fluency and loudness did not significantly differ across the situations. Slightly more eye contact and longer speech was observed during pain questions.

Psychopharmacological management of migraine in children and adolescents.

ABSTRACT Migraine is one of the most common causes of pain and headache seen in the offices of pediatricians and child neurologists. In addition to standard antimigraine treatments (ergots, cyproheptadine), several types of psychotropic medication have been used in the treatment of migraine, primarily prophylactically, with varying degrees of success. Although there is some evidence of their efficacy in treating migraine in adults, there are relatively few studies of their efficacy or safety with children. The authors review the literature on childhood migraine, its relationship to mood and anxiety disorders, modern pathophysiological theories, and current treatment approaches. Despite the widespread use of propranolol, further studies are needed before beta blockers can be considered an effective prophylactic agent in childhood migraine. Antidepressants seem promising in adolescents and children, but more controlled studies are needed to determine their long-term efficacy in children and adolescents. Antidepressant agents with mixed serotonin and norepinephrine action (e.g., amitriptyline) seem more effective than the more selective agents in adults, but it generally remains to be seen whether antimigraine medications that are effective in adults will be equally useful in children and adolescents. Studies on mood and anxiety disorders in children and adolescents might be usefully extended to evaluate migraine headaches.

Tobacco withdrawal signs and symptoms among women with and without a history of depression.

A past history of depression is associated with a decreased likelihood of quitting smoking. Tobacco withdrawal may be a mechanism through which depression history impedes smoking cessation. This research examined the influence of depression history on unmedicated tobacco withdrawal signs (polysomnographic measures of sleep) and symptoms (self-reported urge, negative affect, hunger, and sleep) among women (N= 13). Depression history was associated with differential withdrawal-induced changes in several REM sleep parameters. Self-report and other polysomnography (sleep fragmentation, slow-wave sleep) measures displayed statistically significant withdrawal effects but did not discriminate between depression history groups. These results suggest that REM sleep parameters may be sensitive to differential tobacco withdrawal responses that are not readily apparent through self-reported symptoms.

Cardiovascular reactivity and smoking in coronary prone (type A) and non-coronary prone (type B) subjects.

Twenty-nine Type A subjects, (greater than 75 percentile on the Jenkins Activity Survey) and 28 Type B's (less than 25 percentile of Jenkins) were asked to smoke 1 cigarette (1.0 mg nicotine, 16 mg tar, 14 mg CO) using a standardized smoking procedure. The results showed that both Type A and B subjects experienced significant smoking induced changes in heart rate, skin temperature and pulse transit time. An analysis of covariance also revealed that the Type A subjects exhibited greater heart rate reactivity due to smoking than their type B counter parts. The results are discussed in terms of the possible role of cardiovascular reactivity in the mediation of the subjective and behavioral effects of smoking in the type A individual.

Scheduled reduced smoking: effects on smoking abstinence and potential mechanisms of action.

Although most smokers in our society report that they would like to quit, smoking prevalence rates have remained relatively unchanged during most of the 1990s. This is in contrast to a nearly 50% reduction in prevalence observed over the past 3 decades. Presently, an estimated 25.5% of adults (48 million people) continue to smoke, although most smokers would like to quit. Recent research on the treatment of nicotine dependence has focused primarily on events that occur after the initial cessation period (i.e., the prevention of relapse with behavioral counseling and/or the management of withdrawal symptoms with nicotine replacement therapy). Although these methods are effective, there is evidence that cessation rates may also be enhanced by manipulating smoking behavior prior to quitting. One promising approach is scheduled reduced smoking. Early work with this approach has yielded superior abstinence rates compared to gradual reduction and abrupt "cold turkey" quitting techniques. In this article, we present an overview of research on scheduled reduced smoking and discuss the effects of the treatment on smoking urges, negative affect, and self-efficacy.

An evaluation of a multicomponent treatment program involving scheduled smoking and relapse prevention procedures: initial findings.

In the current study, 34 smokers were treated in a smoking cessation program that involved either a scheduled smoking procedure, or a minimal contact self-help treatment control. The interval smoking program consisted of baseline, cessation, and relapse prevention phases. During baseline, subjects self-monitored smoking and the total hours spent awake. During a 3-week cessation period, the scheduled smoking group progressively increased their intercigarette interval, thereby gradually reducing their total daily intake of nicotine. Smokers were expected to quit on a target date set at the end of this period. Cognitive behavioral interventions and relapse prevention training consisted of behavioral rehearsal of nonsmoking skills in a relapse prone environment. Control subjects were given the American Cancer Society "I Quit Kit", and provided subsequent discussion of its use. The results showed that 53% and 41% of the scheduled smoking group was abstinent at the 6- and 12-month follow-up points, respectively. Controls averaged only 6% for the same periods. Scheduled smoking may be a useful addition to a multicomponent treatment program and further study appears warranted to determine the saliency of the treatment features.

The influence of external information on judgements of pain.

Two studies were performed to assess the relationship between estimates of subjective pain and a graduated ischemic pain stimulus. In the first, 20 subjects received a 7-minute pressure stimulus with a blood-pressure cuff and then rated their pain on a 0-5 scale. At three separate sessions, subjects saw either no feedback or a visual feedback slide that ostensibly depicted cuff pressure. The numbers were either accurate, too high, or too low. Subjective estimates of pain rose with increasing cuff pressure, but pain ratings were higher during high-feedback conditions, and lower during low-feedback conditions than during either the no- or true-feedback conditions, which did not differ. Study 2, which evaluated subjective estimates of actual cuff pressure as well as pain, replicated these results. Both studies suggest that false information may alter a subject's report of pain and of the stimulus causing it.

Smoking cessation. 3: Needed healthcare policy changes.

Smoking is the primary preventable cause of mortality and morbidity in our society, killing more than 430,000 people each year--more than 1,000 a day. Despite this deadly record, the treatment of nicotine dependence has not been integrated into routine medical care. Although professionals from many healthcare fields can be effective providers of smoking cessation treatment, relatively few actually advise patients to quit smoking; and even fewer assist their patients in quitting. Systematic changes in healthcare policies are needed to rectify these problems and improve the provision of smoking cessation services. In this article, the issues of who should be providing cessation treatment, why more providers do not offer this service, and what changes should be made to ensure more widespread inclusion of smoking cessation treatment in future healthcare practice are examined.

Smoking cessation. 1: An overview of research.

Although tobacco smoking has long been recognized as having negative health consequences, more than one quarter of the US adult population smokes. This article presents (a) national trends in the prevalence of tobacco smoking, (b) health consequences associated with tobacco smoking and tobacco's mode of action (how tobacco/nicotine cause the problems), and (c) a brief overview of the smoking cessation treatment literature and several recommendations based on the review of research.

Smoking cessation. 2: Components of effective intervention.

Smoking cessation treatment is an essential component of comprehensive healthcare, but many healthcare providers lack formal training and are hesitant to provide such intervention. The recently published US Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline provided empirically based recommendations to address these issues. The most effective components of smoking cessation include the use of nicotine replacement therapy, provider support and encouragement, and training in such skills as problem solving and coping. Methods of using these recommendations are illustrated, and sample scripts are offered to serve as references for providers from various disciplines who conduct smoking cessation interventions.

The effects of feedback on blood pressure discrimination.

Discrimination of blood pressure in the natural environment as a function of feedback was assessed. Seventeen normotensives screened for blood pressure lability were randomly assigned to two groups. These subjects were then asked to estimate their systolic and diastolic blood pressure values two times per day over a 4-week period. Feedback for accuracy of blood pressure discriminations was implemented across the two groups in a multiple baseline fashion, using a feedback withdrawal condition in Group I to assess maintenance effects over time. Results showed improvement in discrimination accuracy for subjects in both groups when feedback was used, and no decrement in performance over a 2-week period after feedback was removed for subjects in Group I. Discrimination of systolic pressures improved at a slightly faster rate than discrimination of diastolic pressures.

Relationship between frontalis muscle tension and digital skin temperature during EMG biofeedback.

The current study examined the relationship between frontalis EMG and digital skin temperature during EMG biofeedback. 63 subjects participated in 8 40-min. sessions involving a 10-min. adaptation, baseline, feedback, and postfeedback period. The results showed significant reductions in EMG and increases in skin temperature between feedback and baseline periods. Multiple regression analysis showed that baseline EMG levels were the best predictors of skin temperature changes and characterized the relationship between the variables by an over-all negative correlation of .32.