IntroductionTobacco use is highly prevalent in individuals with other substance use disorders (SUDs) and is associated with greater smoking-related illnesses and premature death. To inform intervention strategies, the current study examined the prevalence and clinical features of smoking, including motivation for change, comorbid psychiatric symptoms, and self-regulatory indicators, in a large sample of treatment-seeking SUD patients.Aims and MethodsParticipants were 1893 patients in three clinical programs who were assessed for tobacco use, other substance misuse, psychiatric symptoms, measures of self-regulation (ie, delay discounting, UPPS-P impulsive behavior scales, mindfulness), and readiness rulers (ie, readiness, importance, and confidence). Psychiatric and impulsivity indicators were further examined among patients in precontemplative, contemplative, and actively ready stages of change.ResultsOverall, 73.7% of patients reported combustible tobacco use, with almost half reporting that they were contemplating or actively ready to change. Patients who smoked reported significantly greater psychiatric symptoms, higher illicit substance use, more impulsive delay discounting, and personality traits (ie, positive and negative urgency, lack of premeditation, and sensation seeking), and lower mindfulness. Those who smoked and were actively ready to change their behavior were older, smoked fewer cigarettes per day, and exhibited significantly less impulsive delay discounting and lack of perseverance.ConclusionsThe prevalence of smoking is high in SUD treatment programs and is associated with greater psychiatric symptom severity, substance misuse, psychiatric severity, and impulsivity. Differing levels of readiness suggest three distinct intervention pathways.

IntroductionDifferences in sensitivity to substances are important for understanding variability in addiction propensity. The value of modeling subjective response to nicotine, particularly e-cigarettes, at first use as a predictor of future use remains largely untested.MethodsThis secondary analysis of the Adolescent Brain Cognitive Development (ABCD) Study data included 147 youth (51% female; mean age = 13 at first assessment) who reported vaping of an e-cigarette and provided their subjective response to that experience during the 4 years of baseline and annual follow-up data currently available. Analyses evaluated the longitudinal relationships between subjective response to vaping and subsequent annual e-cigarette episodes (ie, quantity) and use days (ie, frequency) using semi-parametric Bayesian mixture models. Effects were estimated at quantiles (25th, 50th, and 75th) of the e-cigarette use outcomes, representing lower, average (ie, median), and higher use.ResultsGreater pleasurable sensations to vaping at first use predicted greater past-year e-cigarette use for all participants, with youth endorsing higher use exhibiting stronger relationships (bLower use = 0.07–0.10; bMedian use = 0.37–0.75; bHigher use = 22.3–61.4). Greater initial unpleasant sensations to vaping also predicted greater subsequent use (bLower use = 0.16–0.19; bMedian use = 0.54–0.74). Among youth endorsing higher use, unpleasant subjective response was associated with future use quantity (b = 22.00), but not frequency.ConclusionsThese findings suggest that initial subjective response to nicotine vaping in youth is a strong predictor of e-cigarette use behavior up to 4 years later, particularly in those endorsing higher use. This knowledge can be used to enhance early prevention efforts to reduce e-cigarette use in this vulnerable population.ImplicationsThis study advances the initial subjective response to nicotine vaping in youth as a strong predictor of future e-cigarette use behavior, particularly in youth endorsing higher use. This knowledge can be used to help identify risk and protective factors for nicotine use, as well as enhance early prevention efforts to reduce e-cigarette use in this vulnerable population.

IntroductionRelative to other pharmacotherapies for smoking cessation, varenicline has significantly greater efficacy in females; however, sex-specific mechanisms have not yet been investigated. We conducted a secondary analysis of ecological momentary assessment data to assess whether reductions in craving, negative affect, and smoking satisfaction/reward/aversion mediate effects of varenicline on next-day smoking to a greater degree in females (n = 179) relative to males (n = 141).Aims and MethodsData were from a 3-week medication manipulation period during the pre-quit phase of a double-blind randomized placebo-controlled trial investigating extended preloading (4 weeks) versus standard preloading of varenicline (1 week, preceded by 3 weeks of placebo, NCT03262662). Time-invariant multi-level moderated mediation models and time-varying mediation models were utilized.ResultsA significant time-varying indirect effect through craving that increased in magnitude over the pre-quit period was identified only in females. Exploratory analysis found that decreases in psychological reward and smoking satisfaction mediated the relationship between varenicline and reductions in craving only in females. Time-invariant multi-level models did not evidence a significant indirect effect through candidate mediators in males or females; the index of moderated mediation was not significant in any of the models.ConclusionsOur findings suggest that the efficacy of varenicline on reductions in pre-quit smoking in females operates through reductions in craving. Furthermore, reductions in craving may be due to decreases in positive subjective experiences of smoking. Augmenting craving coping strategies as well as reducing smoking reward and satisfaction may be a beneficial approach in females.ImplicationsThis is the first study to investigate sex-specific mediation of varenicline on reductions in pre-quit smoking. Further investigation into varenicline-induced changes in smoking reinforcement and craving is warranted, particularly in females. For example, experimentally manipulating these mediators may inform them as mechanisms for smoking reduction.

IntroductionIn the United States, 80% of adults experiencing homelessness smoke combustible cigarettes. Power to Quit 2 (PTQ2) was a randomized clinical trial to test the efficacy of a combined smoking cessation and alcohol abstinence biobehavioral intervention, Intensive Smoking plus Alcohol (IS + A), versus Usual Care (UC) for adults experiencing homelessness.MethodsPTQ2 was conducted in two urban homeless shelters in the Upper Midwest (2014–-2018). People who smoked and reported hazardous alcohol use (N = 344) were randomized to IS + A (10 sessions of cognitive behavioral therapy for smoking and alcohol cessation plus nicotine replacement therapy [NRT], n = 168) or UC (educational session on smoking and alcohol cessation plus NRT, n = 176). The primary hypothesis was that the intervention would result in greater biochemically verified 7-day point-prevalent smoking abstinence 26 weeks post-intervention compared with UC. Our secondary hypothesis was that the intervention would result in greater 30-day alcohol abstinence 26 weeks post-intervention compared with UC.ResultsAt week 26, the IS + A intervention group did not differ from the UC group in expired carbon-monoxide-verified 7-day point-prevalent smoking abstinence (16.6% vs. 12.8%, P = .47) or rate of self-reported 30-day alcohol abstinence (91.1% vs. 90.2%, P = .75).ConclusionsThe IS + A intervention did not result in significantly better smoking or alcohol cessation outcomes than UC. Nonetheless, trends in the smoking outcome data favored the intervention group, underscoring the importance of continued research into biobehavioral interventions that address smoking and alcohol use among adults experiencing homelessness.ImplicationsThe study highlights the difficulty in observing changes in smoking outcomes in interventions tailored to concurrently address smoking and alcohol use among persons experiencing homelessness. The findings add to existing knowledge by providing evidence about the real-world complexities facing people who use tobacco and alcohol while experiencing homelessness.

IntroductionDespite successful public health campaigns, tobacco use persists as a major cause of preventable illness and death. While tobacco taxation is recognized as an effective control strategy, concerns remain about potential financial strain on lower socioeconomic groups. This study investigates the relationship between household tobacco expenditure and financial stress in Australia, a country with high tobacco taxes and declining smoking rates.MethodsHousehold data from the 2015-16 Australian Household Expenditure Survey were analyzed (N = 10 036). Financial stress was measured using a scale based on nine self-reported indicators. Respondents were asked to report if their household had experienced any of these difficulties, for example, inability to pay utility bills or going without meals. Negative binomial regression models assessed the association between tobacco expenditure share and financial stress, adjusting for sociodemographic factors, household wealth, and other expenditures.ResultsFinancial stress was more prevalent among households that did (45.0%; (95% CI = 42.5 to 47.5)) versus did not (25.4%) purchase tobacco. All levels of tobacco expenditure were significantly associated with higher financial stress bivariably, after controlling for covariates. For instance, households in the second-lowest tobacco expenditure share quintile had a higher mean financial stress score than non-purchasing households (RR = 1.59, CI = 1.36 to 1.85, p < .001).DiscussionIn Australia, financial stress is prevalent among tobacco-purchasing households, and household tobacco expenditure is significantly associated with increased financial stress even at modest levels of spending, that is, the lower quintiles of tobacco expenditure. These findings underscore the need for targeted policies to mitigate financial strain and support smoking cessation among vulnerable populations.

PurposeThis study sought to identify the predominant factors associated with tobacco and marijuana/cannabis use among adolescents according to their sexual identity.MethodsUsing the 2023 National Youth Tobacco Survey, we examined current use of e-cigarettes, cigarettes, and marijuana/cannabis vaping among adolescents. We used dominance analyses and logistic regression models to assess the relative importance of factors linked to tobacco and marijuana/cannabis use. The analyses were stratified by sexual identity (straight, sexual minorities, unsure) and grade levels (middle-school vs. high-school).ResultsThe study sample includes 6654 middle-school and 8274 high-school students. Three themes emerge from the dominance analysis. First, exposure to e-cigarette or cigarette use at home or in vehicles consistently ranked as the leading factor associated with smoking and vaping across school levels and sexual identity, explaining up to 44% of the predicted variance. Second, the perception of occasional e-cigarette or cigarette use as little to no harm was a top factor, linked to e-cigarette use among sexual minority students and straight high-school students, as well as cigarette use among straight students and sexual minority high-school students. It explained up to 21.6% and 26.5% of the variance in current e-cigarette and cigarette use, respectively. Third, mental stress was a dominant factor associated with tobacco and marijuana/cannabis use among sexual minority middle-school students, explaining up to 21% of the variance.ConclusionsThis study identifies modifiable factors linked to adolescent tobacco and marijuana use. Public health initiatives targeting these factors may reduce smoking and vaping, especially among sexual minority adolescents.ImplicationsAdolescents in the LGBTQ+ community use tobacco and marijuana at higher rates than their straight peers. This study offers insight into the relative importance of a variety of sociodemographic and environmental factors contributing to increased use. The most dominant factors, identified as immediate environmental exposure, e-cigarette risk perceptions, and mental stress should be prioritized when developing targeted interventions to reduce smoking and vaping in this priority population.

IntroductionThe effectiveness of nicotine replacement therapy (NRT) on smokeless tobacco (SLT) users is underexplored in India, with prior research primarily focusing on smokers. This study assessed and compared the effectiveness of combining behavioral intervention (BI) and NRT with BI alone on smoking and SLT cessation.MethodsThis 1.5-year prospective, open-label, three-arm parallel-group randomized controlled trial was conducted at the Tobacco Cessation Clinic, SCB Dental College and Hospital, Odisha, India. The three intervention groups—BI, BI + nicotine patch, and BI + nicotine gum—were assessed using a prevalidated proforma on sociodemographics, relevant medical and dental history, oral hygiene practices, and previous tobacco use patterns.ResultsThe study enrolled 130 participants. At 26 weeks, 63.3% (19/30) in the BI + patch and 52.9% (18/34) in the BI + gum achieved abstinence, compared to 24.1% (7/29) in the BI group. The odds ratio (OR), 95% confidence interval (CI); p-value of abstinence was 6.03 (1.90–19.15; p = .003) for BI + patch, and 3.25 (1.08–9.78; p = .035) for BI + gum. Among SLT users, abstinence was achieved in 70.59% (12/17) with BI + patch (OR 6.40, 95% CI: 1.57–26.03; p = .010) and 53.85% (14/26) with BI + gum (OR 3.11, 95% CI: .92–10.47; p = .067) versus 27.27% (6/22) with BI alone. Both intervention groups demonstrated significantly reduced relapse risk versus BI alone (Hazard ratio [HR] 0.45, 95% CI: .24–.83; p = .011) for BI + patch and HR 0.40, 95% CI: .22–.74; p = .003 for BI + gum.ConclusionCombination therapy (BI + NRT) is more effective than BI alone. The BI + patch combination is more effective than BI + gum and BI alone. The NRT intervention groups had higher abstinence rates and reduced relapses than the standard BI group. Further studies are required to validate these findings.

IntroductionDichotomized smoking abstinence (abstinent/smoking) is the standard outcome for clinical trials, but obscures smoking behavior change. Examining both smoking probability and smoking rate as outcomes may identify unique barriers to cessation (eg, craving, affect) among individuals who are receiving treatment but unable to quit.Aims and MethodsTwo-part latent growth modeling examined daily smoking probability and smoking rate during the first week of the quit attempt using self-reported cigarettes per day. Smoking trajectories and the effect of 12 weeks of varenicline (vs. placebo), craving, negative affect (NA), and positive affect (PA) on these trajectories were examined among 828 adults in a randomized smoking cessation trial (NCT01314001).ResultsOn average, smoking probability was 46% on the target quit day and increased to 50% later into the week (ps < .01). Among participants continuing to smoke, daily smoking rates were reduced to 27% of baseline rates and remained stable throughout the week (p = .62). Varenicline use was associated with lower smoking probability (p < .001). Higher craving and NA were associated with a higher smoking probability and higher smoking rates (ps ≤ .05). Higher PA was associated with a higher smoking probability, but lower smoking rates (ps < .04).ConclusionsModeling smoking behavior, versus dichotomized abstinence, reveals differences in predictors of treatment effects. Results suggest smoking probability increases early into the quit attempt while daily smoking rates remain stable. Varenicline increases the probability of abstinence. Smoking abstinence and lower smoking rates were both associated with lower cravings and NA. However, PA demonstrated differential relationships with abstinence and smoking rates.ImplicationsThis study expands clinical outcomes beyond dichotomous smoking abstinence by conducting preliminary two-part latent growth models to evaluate treatment processes and barriers to cessation on both smoking probability and smoking rate. This approach provides a complementary understanding of treatment effects and predictors of outcomes. Results suggest time, treatment, craving, and affect may have differential relationships with smoking probability versus smoking rates which would not be captured in traditional modeling for clinical trial outcomes.

IntroductionDual use of combustible cigarettes and e-cigarettes is the most common multiple tobacco-use behavior in the United States, but its long-term health impact remains unclear. Biomarkers of exposure (BOE) can help identify potential health risks of dual use.MethodsWe analyzed data from 2,679 adult participants from Wave 5 of the Population Assessment on Tobacco and Health Study, a U.S. nationally representative study, including individuals reporting current exclusive cigarette use (n = 1,913), exclusive e-cigarette use (n = 316), and dual use (n = 450). Eight subgroups were created based on self-reported high/low (above/below mean) cigarettes per day (CPD) and days of e-cigarette use in past the 30 days (ECIG). Adjusted geometric mean concentrations were compared for total nicotine equivalents, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), three volatile organic compounds (VOCs), and heavy metals (lead and cadmium).ResultsIndividuals reporting dual use did not differ from those reporting exclusive cigarette use on CPD (13.1 vs. 11.8, respectively). Dual-use groups with high CPD had higher levels of NNAL and VOCs compared to those with low CPD (eg, NNAL for high CPD/high ECIG: 257.07 ng/mg creatinine vs. low CPD/high ECIG: 64.57 ng/mg creatinine, p < .001; high CPD/low ECIG: 312.02 ng/mg creatinine vs. low CPD/low ECIG: 144.11 ng/mg creatinine, p < .001). Cigarette use (dual or exclusive use) was generally associated with higher BOE than exclusive e-cigarette use, though metal exposure did not differ between groups.ConclusionsDual use and exclusive cigarette use are associated with higher toxicant exposure compared to exclusive e-cigarette use.ImplicationsIn this population-based cross-sectional study, individuals reporting dual use appear to have nicotine and toxicant exposure at least at the same level as those using cigarettes alone and higher than exclusive e-cigarette use (except for metals). Given the adverse health consequences of dual use, including potential cancer risk, our findings highlight the need for clinicians and public health practitioners to increase awareness of the potential risks associated with dual use.

IntroductionIn May 2020, the United Kingdom banned menthol as a characteristic flavor in cigarettes. This study aimed to test cigarettes on sale in England in 2021–2022 for menthol and other characterizing flavors, through sensory and chemical testing.Aims and MethodsAssessments were conducted for 20 cigarette brands (16 tests and four reference products). An untrained consumer panel of 50 people who smoked daily were each randomized to smell one of the two blocks of 10 unburnt cigarettes in duplicate (50 assessments per product). Using the Check-All-That-Apply method, participants assessed the presence of 22 odor attributes, including menthol/mint. For each test and reference cigarette, proportions of assessments that identified menthol/mint, “fruity,” “confectionary” and “non-tobacco” odors were identified and compared accounting for the within-participant duplicate testing. For each cigarette, the content of 34 flavoring chemicals (16 cooling/minty) was analyzed using gas chromatography-mass spectrometry.ResultsFour of the sixteen test cigarette products were more frequently identified by participants as having a menthol/mint odor than reference products and had detectable levels of menthol/mint in the chemical tests. For four other test products, there was some discordance between the chemical and sensory assessments. Sensory testing also identified a fruity odor in six test products and a confectionary odor in one test product. The compounds dihydroxyacetone and triacetin were detected above the LLOQ in all products.ConclusionsFour cigarette products for sale in England in 2021–2022 appeared non-compliant with the ban on menthol as a characterizing flavor in sensory and chemical tests.ImplicationsMenthol is known to enhance the appeal of tobacco products, particularly among young people. The subjective nature of determining “characterizing” flavors in tobacco products creates compliance challenges. Our findings suggest that more stringent regulatory policies around flavoring additives used in tobacco products might be necessary. An outright ban on menthol, other minty flavorings, and additives not essential to the manufacturing process could provide clearer guidelines for manufacturers and regulators.