Posttraumatic stress symptoms and smoking to reduce negative affect: an investigation of trauma-exposed daily smokers

Smoking as a Marker of Comorbid Vulnerability Among Persons with Probable Posttraumatic Stress Disorder Who Engage in Hazardous Drinking

Background: Persons with posttraumatic stress disorder (PTSD) compared to those without evince high rates of hazardous drinking, or patterns of alcohol consumption that increase the risk for harmful consequences. One potential marker of vulnerability for PTSD-hazardous drinking comorbidity may be smoking behavior. Individuals with PTSD have a higher prevalence of smoking and smoke at higher rates. Smokers, compared to nonsmokers, are more apt to engage in hazardous alcohol use. Notably, there is a need to expand research on smoking in the context of PTSD and hazardous drinking to inform treatment of these morbidities. Objective: The present cross-sectional investigation sought to examine smoking status as a marker of risk among persons with probable PTSD who engage in hazardous drinking (N = 647; Mage = 38.90 years, SD = 10.71; 51.2% female). Results: Results indicated that trauma-exposed smokers, compared to non-smokers, evinced greater severity of PTSD symptoms, depression, emotion regulation difficulties, hazardous drinking, and substance use problems, with small effect sizes. No statistically significant group differences were found for anxiety symptom severity. Secondary analyses among only smokers supported an interrelation between cigarette dependence and each of the criterion variables that demonstrated statistically significant group differences. Specifically, cigarette dependence was statistically significantly and incrementally related to PTSD symptom severity, depression, emotion regulation difficulties, more severe hazardous drinking, and a greater degree of substance use problems. Conclusions: Overall, the current investigation found that smoking status among persons with probable PTSD who engaged in hazardous drinking was associated with numerous indicators of mental health and substance use vulnerability.

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

A network approach to the symptom-level associations between smoking and posttraumatic stress disorder (PTSD) among young adults exposed to childhood sexual abuse

Background

Previous empirical literature has examined the associations between childhood sexual abuse (CSA) exposure, posttraumatic stress disorder (PTSD), and smoking. However, few studies examined symptom-level associations between smoking and PTSD among CSA victims. Thus, the aims of this study were 1) to explore symptom-level associations between smoking and PTSD among combustible cigarette (CC) and electronic cigarette (EC) users exposed to CSA and 2) to compare the differences manifested in two network structures between EC and CC users with CSA experiences.

Methods

This cross-sectional study covers all 63 universities and colleges in Jilin province, China, from October 26 to November 18, 2021. A total of 117 769 students participated in this study, while 3479 young adults were exposed to CSA (3.62%, 95% CI = 3.50%-3.73%). Childhood sexual abuse, PTSD, and smoking symptoms were measured using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), 10-item Trauma Screening Questionnaire (TSQ-10), and the 6-item Fagerstrom Test for Nicotine Dependence (FTND-6), respectively. In addition, network analysis was applied to analyse psychopathological symptoms between EC and CC users with CSA experiences. Both the edges and centralities were computed, and the network properties were compared among the two groups.

Results

Four symptoms of PTSD (i.e. emotional cue reactivity, hypervigilance, nightmares, and difficulty concentrating) were both central and bridge symptoms between PTSD and smoking among EC and CC users with CSA experiences. Moreover, compared with CC users with CSA, there were significantly stronger associations between "nightmares" - "difficulty with restrictions" and "irritability / anger" - "more during wake up" among young EC users with CSA.

Conclusions

The four symptoms (i.e. emotional cue reactivity, hypervigilance, nightmares, and difficulty concentrating) were keystones for treatments or interventions targeting these CSA victims with PTSD and smoking symptoms. Increasing efforts should be taken to restrict morning smoking among EC users with CSA. In addition, target interventions and strategies founded on these core symptoms and associations should be implemented to relieve the comorbid PTSD and smoking in EC and CC users with CSA experiences.

Trauma exposure and smoking outcomes: The indirect effects of anxious and depressive symptoms

With a direct link between traumatic stress and poor smoking outcomes established, there is a clinically important need to identify underlying, targetable mechanisms that maintain these relations. The present study employed a parallel mediation model to assess the competing explanatory significance of four distinct facets of depression and anxiety (general anxiety, anxious arousal, general depression, and anhedonic depression) in the relation between traumatic load and perceived barriers for quitting smoking, severity of psychosomatic problems experienced when attempting to quit smoking in the past, and negative reinforcement expectancies related to smoking among 98 adult trauma-exposed daily smokers (Mage = 44.64, SD = 10.66). Results showed that only general anxiety symptoms, when controlling for the competing facets of depression and anxiety, had a statistically significant indirect effect on the relation between traumatic load and all smoking processes, such that general anxiety symptoms significantly, indirectly influenced the relation between traumatic load and barriers for smoking cessation (ab = 0.95, 95% CI [0.163, 0.2.14]), smoking quit problems (ab = 0.07, 95% CI [0.009, 0.165]), and negative reinforcement smoking expectancies (ab = 0.16, 95% CI [0.025, 0.399]). Anxious arousal demonstrated an indirect effect for trauma load on only negative reinforcement smoking expectancies (ab = -0.15, 95% CI [-0.345, -0.023]). The current findings highlight the potential importance of general anxiety symptoms as a targetable mechanism for smoking cessation treatments for trauma-exposed smokers.

Unique effects of nicotine across the lifespan

Smoking remains the leading cause of preventable death in the United States. Although combustible cigarettes are largely being replaced by tobacco-free products, nicotine use continues to increase in vulnerable populations, including youth, adolescents, and pregnant women. Nicotine exerts unique effects on specific brain regions during distinct developmental periods due to the dynamic expression of nicotinic acetylcholine receptors (nAChRs) throughout the lifespan. Nicotine exposure is a health concern not only for adults but also has neurotoxic effects on the fetus, newborn, child, and adolescent. In this review, we aim to highlight the dynamic roles of nAChRs throughout gestation, adolescence, and adulthood. We also provide clinical and preclinical evidence of the neurodevelopmental, cognitive, and behavioral consequences of nicotine exposure at different developmental periods. This comprehensive review highlights unique effects of nicotine throughout the lifespan to help elucidate interventions and public health measures to protect sensitive populations from nicotine exposure.

A cross-sectional examination of caregiver mental health and childhood cancer survivors' tobacco, alcohol, and marijuana use

PURPOSE

As childhood cancer survivors (CCS) age, they face numerous long-term consequences, or late effects, from their cancer treatments. Late effects may be mitigated by health-promoting behaviors, including the avoidance of substance use. CCS with greater depression symptomology have reported greater substance use, but whether their habits are associated with the mental health of their caregivers is unknown. The aim of this study was to examine caregiver psychosocial correlates of CCS substance use.

METHODS

This study utilizes data from the Project Forward pilot study, which collected data from 129 CCS-caregiver dyads (CCS mean age = 19.43, SD = 2.78; years since diagnosis = 7.62, SD = 2.06) from two large hospitals in Los Angeles County. CCS provided self-reported information on substance use, while caregivers self-reported on posttraumatic stress symptomatology (PTSS) associated with their child's cancer and current depressive symptoms.

RESULTS

Among CCS, prior 30-day tobacco, marijuana, binge drinking, and polysubstance use were 12.50%, 14.17%, 13.18%, and 12.40%. In multivariable logistic regression models, caregiver PTSS was independently positively associated with CCS tobacco use. No other significant relationships between caregiver mental health (PTSS or depressive symptoms) and CCS substance use were observed.

CONCLUSION

These findings suggest that caregiver PTSS is partially associated with CCS behavioral health. Survivorship care may improve tobacco use prevention efforts by incorporating family or caregiver mental health needs. Future research should examine the potential mediating effect of CCS mental health, including depressive symptoms, on this relationship.

Perceived Stress Mediates the Association between Deployment Sexual Trauma and Nicotine Dependence in Women Veterans

BACKGROUND

Rates of smoking and related health consequences are higher for women veterans as compared with their civilian counterparts, and trauma is a known risk factor associated with smoking. Military sexual trauma is prevalent among women veterans and associated with deleterious health outcomes, including tobacco use. However, research has not examined variables that may explain this association. The purpose of the present study was to examine the association between deployment sexual trauma (DST; military sexual trauma that occurs during deployment) and nicotine dependence, and whether perceived stress is a potential explanatory variable (i.e., mediator) in this relationship.

METHODS

Cross-sectional associations and Hayes mediation models were examined using baseline interview data from the Survey of Experiences of Returning Veterans sample (352 recently returned women veterans).

RESULTS

DST was associated with postdeployment nicotine dependence and greater perceived stress. Further, perceived stress was a significant mediator between DST and binary nicotine dependence (indirect effect [standard error] of DST on nicotine dependence through perceived stress, 0.04 [0.01]; 95% confidence interval, 0.01-0.07; odds ratio, 1.04; p < .01) when controlling for education.

CONCLUSIONS

Findings suggest that perceived stress may be a clinical target for decreasing nicotine dependence among women veterans who have experienced DST.

Longitudinal Examination of the Influence of Individual Posttraumatic Stress Disorder Symptoms and Clusters of Symptoms on the Initiation of Cigarette Smoking

OBJECTIVES

The aim of this study was to determine whether specific individual posttraumatic stress disorder (PTSD) symptoms or symptom clusters predict cigarette smoking initiation.

METHODS

Longitudinal data from the Millennium Cohort Study were used to estimate the relative risk for smoking initiation associated with PTSD symptoms among 2 groups: (1) all individuals who initially indicated they were nonsmokers (n = 44,968, main sample) and (2) a subset of the main sample who screened positive for PTSD (n = 1622). Participants were military service members who completed triennial comprehensive surveys that included assessments of smoking and PTSD symptoms. Complementary log-log models were fit to estimate the relative risk for subsequent smoking initiation associated with each of the 17 symptoms that comprise the PTSD Checklist and 5 symptom clusters. Models were adjusted for demographics, military factors, comorbid conditions, and other PTSD symptoms or clusters.

RESULTS

In the main sample, no individual symptoms or clusters predicted smoking initiation. However, in the subset with PTSD, the symptoms "feeling irritable or having angry outbursts" (relative risk [RR] 1.41, 95% confidence interval [CI] 1.13-1.76) and "feeling as though your future will somehow be cut short" (RR 1.19, 95% CI 1.02-1.40) were associated with increased risk for subsequent smoking initiation.

CONCLUSIONS

Certain PTSD symptoms were associated with higher risk for smoking initiation among current and former service members with PTSD. These results may help identify individuals who might benefit from more intensive smoking prevention efforts included with PTSD treatment.

Posttraumatic stress disorder and cigarette smoking: A systematic review

BACKGROUND

Previous reviews of the PTSD and cigarette smoking literature showed high PTSD-smoking comorbidity and problematic smoking outcomes (Feldner et al., 2007, Clinical Psychology Review, 27, 14-45; Fu et al., 2007, Nicotine & Tobacco Research, 9, 1071-1084). However, past reviews also noted several prominent gaps in the literature, including a lack of etiological work examining underlying mechanisms and research on specialized PTSD-smoking treatments. The present review summarizes an extensive body of research conducted since the previous reviews targeting these areas of need.

METHODS

Literature searches identified 66 empirical studies specific to smoking and PTSD.

RESULTS

Smokers were approximately twice more likely to have PTSD than nonsmokers in the general population, and individuals with PTSD were approximately twice as likely to be current smokers. Smokers with PTSD evidenced more negative affect, trauma history, and comorbid psychiatric history, as well as quit attempts and higher relapse rates. PTSD symptoms were associated with expectations that smoking would reduce negative affect, which, in turn, was associated with increased smoking rate and nicotine dependence. Male sex was associated with nicotine dependence and PTSD avoidance, while the relationship between PTSD and smoking relapse due to withdrawal was stronger in females. Specialized, integrated PTSD and smoking cessation treatments showed promise in increasing quit success relative to standard care in randomized trials.

CONCLUSIONS

Rates of PTSD-smoking co-occurrence remain high. Notable gains have been made in relevant epidemiological and etiological research, although more work is needed in trauma-specific subpopulations. Several promising specialized treatments for comorbid smoking-PTSD have been developed and empirically tested but require replication.

Posttraumatic stress disorder and tobacco use: A systematic review and meta-analysis

Posttraumatic stress disorder (PTSD) and tobacco use are prevalent conditions that co-occur at striking rates in the US. Previous reviews examined prevalence and factors associated with cigarette smoking among individuals with PTSD but have not been summarized since 2007. Moreover, none explored rates and factors associated with the use of other tobacco products. This study aimed to systematically review the most recent literature examining the comorbidity of PTSD and tobacco use to provide prevalence rates, as well as summarize the literature exploring other factors associated with tobacco use among individuals with PTSD. Studies were identified using a systematic search of keywords related to tobacco use and PTSD within the following databases: PubMed, PsycINFO, Web of Knowledge, CINAHL, PsycARTICLES, and Cochrane Clinical Trials Library. The studies included in this review (N = 66) showed that the prevalence of current use of tobacco products in individuals with PTSD was 24.0% and the rate of PTSD among users of tobacco products was 20.2%. Additionally, results demonstrated that individuals with PTSD present with high levels of nicotine dependence and heavy use of tobacco products, as well as underscore the importance of negative emotional states as a contributing factor to tobacco use among individuals with PTSD. It is imperative that future studies continue monitoring tobacco use among individuals with PTSD while also assessing factors identified as having a prominent role in tobacco use among individuals with PTSD. These findings also demonstrate the need for more innovative approaches to reduce the pervasive tobacco use among individuals with PTSD.

Smoking and Posttraumatic Stress Disorder Symptomatology in Orofacial Pain

To explore the impact of interactions between smoking and symptoms of posttraumatic stress disorder (PTSD) on pain intensity, psychological distress, and pain-related functioning in patients with orofacial pain, a retrospective review was conducted of data obtained during evaluations of 610 new patients with a temporomandibular disorder who also reported a history of a traumatic event. Pain-related outcomes included measures of pain intensity, psychological distress, and pain-related functioning. Main effects of smoking status and PTSD symptom severity on pain-related outcomes were evaluated with linear regression analyses. Further analyses tested interactions between smoking status and PTSD symptom severity on pain-related outcomes. PTSD symptom severity and smoking predicted worse pain-related outcomes. Interaction analyses between PTSD symptom severity and smoking status revealed that smoking attenuated the impact of PTSD symptom severity on affective distress, although this effect was not found at high levels of PTSD symptom severity. No other significant interactions were found, but the present results identifying smoking as an ineffective coping mechanism and the likely role of inaccurate outcome expectancies support the importance of smoking cessation efforts in patients with orofacial pain. Smoking is a maladaptive mechanism for coping with pain that carries significant health- and pain-related risks while failing to fulfill smokers' expectations of affect regulation, particularly among persons with orofacial pain who also have high levels of PTSD symptom severity. Addressing smoking cessation is a critical component of comprehensive treatment. Further research is needed to develop more effective ways to help patients with pain and/or PTSD to replace smoking with more effective coping strategies.

Post-traumatic stress disorder symptoms, underlying affective vulnerabilities, and smoking for affect regulation

BACKGROUND AND OBJECTIVES

Post-traumatic stress disorder (PTSD) is overrepresented among cigarette smokers. It has been hypothesized that those with PTSD smoke to alleviate negative affect and counteract deficient positive affect commonly associated with the disorder; however, limited research has examined associations between PTSD symptoms, smoking motives, and affective vulnerability factors. In the current study, we examined (1) whether PTSD symptoms were associated with positive reinforcement and negative reinforcement smoking motives; and (2) whether two affective vulnerability factors implicated in PTSD-anxiety sensitivity and anhedonia-mediated relationships between PTSD symptoms and smoking motives.

METHODS

Data were drawn from a community sample of non-treatment-seeking smokers recruited without regard for trauma history (N = 342; 10+ cig/day). We used the Posttraumatic Stress Disorder Checklist-Civilian Version (PCL-C) to assess overall PTSD symptom severity as well as individual PTSD subfactors.

RESULTS

Overall, PTSD symptom severity was significantly associated with negative reinforcement, but not positive reinforcement, smoking motives. Variation in anxiety sensitivity significantly mediated the relation between PTSD symptom severity and negative reinforcement smoking motives, whereas anhedonia did not. Regarding PTSD subfactors, emotional numbing was the only PTSD subfactor associated with smoking rate, while re-experiencing symptoms were uniquely associated with both positive reinforcement and negative reinforcement smoking motives.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings suggest that anxiety sensitivity may be an important feature associated with PTSD that enhances motivation to smoke for negative reinforcement purposes. Smoking cessation interventions that alleviate anxiety sensitivity and enhance coping with negative affect may be useful for smokers with elevated PTSD symptoms.

Cognitive Dysfunction, Affective States, and Vulnerability to Nicotine Addiction: A Multifactorial Perspective

Although smoking prevalence has declined in recent years, certain subpopulations continue to smoke at disproportionately high rates and show resistance to cessation treatments. Individuals showing cognitive and affective impairments, including emotional distress and deficits in attention, memory, and inhibitory control, particularly in the context of psychiatric conditions, such as attention-deficit hyperactivity disorder, schizophrenia, and mood disorders, are at higher risk for tobacco addiction. Nicotine has been shown to improve cognitive and emotional processing in some conditions, including during tobacco abstinence. Self-medication of cognitive deficits or negative affect has been proposed to underlie high rates of tobacco smoking among people with psychiatric disorders. However, pre-existing cognitive and mood disorders may also influence the development and maintenance of nicotine dependence, by biasing nicotine-induced alterations in information processing and associative learning, decision-making, and inhibitory control. Here, we discuss the potential forms of contribution of cognitive and affective deficits to nicotine addiction-related processes, by reviewing major clinical and preclinical studies investigating either the procognitive and therapeutic action of nicotine or the putative primary role of cognitive and emotional impairments in addiction-like features.

Dispositional mindfulness in trauma recovery: Prospective relations and mediating mechanisms

This study examined the protective properties and candidate mediating processes (cognitive fusion and cognitive suppression) linking dispositional mindfulness to distal risk factors (negative affect, anxiety sensitivity, rumination) and psychopathology symptom outcomes (depression and posttraumatic stress symptoms) following trauma exposure. To do so, a community-based sample of adults was longitudinally studied in the six-months following exposure--within 30-days (T1), 3-months (T2), and 6-months (T3)--to a shared disaster-related potentially traumatic event (PTE). Specifically, we found that cognitive fusion predicted, and mediated, the effect of mindfulness on outcomes related to distress post-trauma including negative affect, depression and posttraumatic stress symptoms. Complementary to these effects, we found that cognitive suppression predicted, and mediated, the effect of mindfulness on distal risk factors linked to negative self-referential processes including rumination and anxiety sensitivity. Findings are discussed with respect to their theoretical and clinical implications for the potential role and mechanisms of mindfulness in recovery following trauma.

Anxiety sensitivity mediates the association between post-traumatic stress symptom severity and interoceptive threat-related smoking abstinence expectancies among World Trade Center disaster-exposed smokers

INTRODUCTION

Anxiety sensitivity (fear of internal anxiety-relevant bodily sensations) is an individual difference variable that is associated with the development and maintenance of posttraumatic stress disorder (PTSD) and is also involved in the maintenance/relapse of smoking. Abstinence expectancies are crucial to smoking maintenance, yet, past work has not explored how PTSD symptom severity and anxiety sensitivity contribute to them.

METHOD

Participants were 122 treatment-seeking daily smokers (36.1% female; Mage=49.2, SD=9.7; cigarettes per day: M=18.3, SD=15.2) who were exposed to the World Trade Center disaster on September 11, 2001 and responded to an advertisement for a clinical smoking cessation trial. The indirect effect of anxiety sensitivity was tested in terms of the effect of PTSD symptom severity on smoking abstinence expectancies (i.e., anxiety sensitivity as a statistical mediator).

RESULTS

PTSD symptom severity was positively associated with interoceptive threat-related smoking abstinence expectancies: expecting harmful consequences (β=.33, p<.001) and somatic symptoms (β=.26, p=.007). PTSD symptom severity was also significantly associated with anxiety sensitivity (β=.27, p=.003). Anxiety sensitivity mediated the association between PTSD symptom severity and expectancies about the harmful consequences (β=.09, CI95%=.02-.21; ΔR(2)=.076) and somatic symptoms (β=.11, CI95%=.02-.24; ΔR(2)=.123) from smoking abstinence, with medium effect sizes (Κ(2)=.08 and .10, respectively).

CONCLUSIONS

These data document the role of PTSD symptoms in threat-based expectancies about smoking abstinence and suggest anxiety sensitivity may underlie the associations between PTSD symptom severity and abstinence expectancies.

Posttraumatic stress symptoms and smoking among World Trade Center disaster responders: A longitudinal investigation

PURPOSE

The current longitudinal study examined posttraumatic stress disorder (PTSD) symptom severity in relation to smoking abstinence and reduction over time among responders to the World Trade Center (WTC) disaster.

METHOD

Participants were 763 police and 1881 non-traditional (e.g., construction workers) WTC responders who reported being smokers at an initial examination obtained between July 2002 and July 2011 at the WTC Health Program (WTC-HP). WTC responders were reassessed, on average, 2.5 years later.

RESULTS

For police WTC responders, higher levels of WTC-related PTSD symptoms at the initial visit were associated with a decreased likelihood of smoking abstinence (OR=0.98, p=.002) and with decreased smoking reduction (β=-.06, p=.012) at the follow-up visit. WTC-related PTSD symptom severity was not related to likelihood of smoking abstinence or change in number of cigarettes smoked among non-traditional responders. Post hoc analyses suggested that for police, hyperarousal PTSD symptoms were predictive of decreased abstinence likelihood at the follow-up visit (OR=0.56, p=.006).

DISCUSSION

The present findings suggest that PTSD symptoms may be differentially related to smoking behavior among police and non-traditional WTC responders in a naturalistic, longitudinal investigation. Future work may benefit from exploring further which aspects of PTSD (as compared to each other and to common variance) explain smoking maintenance.

Posttraumatic Stress Symptoms and Their Association With Smoking Outcome Expectancies Among Homeless Smokers in Boston

INTRODUCTION

Cigarette smoking and traumatic life experiences are each common among homeless adults, but the prevalence and correlates of posttraumatic stress disorder (PTSD) symptoms among homeless smokers are not known. We assessed symptoms of PTSD and their association with smoking outcome expectancies in a sample of homeless smokers in Boston.

METHODS

We used time-location sampling to conduct an in-person survey of homeless adult smokers using Boston Health Care for the Homeless Program clinical services. We assessed symptoms of PTSD with the PTSD Checklist-Civilian version and considered scores at least 14 as positive. We used the Smoking Effects Questionnaire to assess positive and negative smoking outcome expectancies. We modeled the associations between PTSD screening status and smoking expectancies using design-adjusted linear regression.

RESULTS

Eighty-six percent of eligible individuals participated (N = 306). Sixty-eight percent of participants screened positive for PTSD. Screen-positive respondents were younger (P = .001), more likely to report fair/poor health (P = .01), chronic obstructive pulmonary disease (P = .02), and past-month hallucinations (P = .004), and had greater drug (P < .001) and alcohol (P < .001) use severity and cigarette dependence (P = .002). In analyses controlling for these confounders, PTSD screen-positive participants more strongly endorsed smoking to reduce negative affect (P = .01), smoking for social benefits (P = .002), and smoking for weight control (P = .03). Exploratory analyses suggested that these associations were driven by avoidance/numbing and re-experiencing symptoms.

CONCLUSIONS

Symptoms of posttraumatic stress are common among homeless smokers and strongly associated with positive smoking outcome expectancies. Tobacco cessation programs for this population should consider screening for PTSD and fostering a trauma-sensitive treatment environment.

IMPLICATIONS

In this study of homeless cigarette smokers in Boston, over two-thirds of participants screened positive for PTSD. PTSD screen-positive respondents more strongly endorsed multiple positive smoking outcome expectancies than screen-negative individuals. These findings suggest that the psychological sequelae of trauma may be a pervasive but under-recognized factor impacting the persistence of smoking among homeless people. Tobacco cessation programs for this population should consider screening for PTSD, fostering a trauma-sensitive treatment environment, and incorporating strategies that have shown promise in smokers with PTSD.

Smoking cessation and reduction in people with chronic mental illness

The high prevalence of cigarette smoking and tobacco related morbidity and mortality in people with chronic mental illness is well documented. This review summarizes results from studies of smoking cessation treatments in people with schizophrenia, depression, anxiety disorders, and post-traumatic stress disorder. It also summarizes experimental studies aimed at identifying biopsychosocial mechanisms that underlie the high smoking rates seen in people with these disorders. Research indicates that smokers with chronic mental illness can quit with standard cessation approaches with minimal effects on psychiatric symptoms. Although some studies have noted high relapse rates, longer maintenance on pharmacotherapy reduces rates of relapse without untoward effects on psychiatric symptoms. Similar biopsychosocial mechanisms are thought to be involved in the initiation and persistence of smoking in patients with different disorders. An appreciation of these common factors may aid the development of novel tobacco treatments for people with chronic mental illness. Novel nicotine and tobacco products such as electronic cigarettes and very low nicotine content cigarettes may also be used to improve smoking cessation rates in people with chronic mental illness.

Trauma exposure and cigarette smoking: the impact of negative affect and affect-regulatory smoking motives

Cognitive-affective mechanisms related to the maintenance of smoking among trauma-exposed individuals are largely unknown. Cross-sectional data from trauma-exposed treatment-seeking smokers (n = 283) were utilized to test a series of multiple mediator models of trauma exposure and smoking, as mediated by the sequential effects of negative affect and affect-modulation smoking motives. The sequential effects of both mediators indirectly predicted the effect of greater trauma exposure types on nicotine dependence, a biochemical index of smoking, perceived barriers to smoking cessation, and greater withdrawal-related problems during past quit attempts. Negative affect and affect-modulation motives for smoking may contribute to the trauma-smoking association.

Posttraumatic stress and emotion dysregulation: Relationships with smoking to reduce negative affect and barriers to smoking cessation

INTRODUCTION

Many cigarette smokers have experienced a traumatic event, and elevated posttraumatic stress symptoms (PTSS) are associated with increased smoking levels. Previous research has found that elevated PTSS are associated with smoking to cope with negative affect, and it has been posited that perceptions of being unable to cope with the consequences of smoking cessation interfere with smoking cessation in this population. However, the mechanism of the relationship between PTSS and these smoking maintenance factors (i.e., smoking to reduce negative affect and barriers to cessation) has not been established. Emotion dysregulation is one potential mechanism as it is associated with PTSS as well as addictive behavior aimed at avoiding and reducing negative emotional states.

METHODS

We cross-sectionally tested the hypotheses that 1) PTSS and emotion dysregulation would be incrementally associated with smoking to reduce negative affect and barriers to cessation, and 2) that emotion dysregulation would mediate the relationships between PTSS, smoking to reduce negative affect, and barriers to cessation among a community sample of trauma-exposed individuals presenting for smoking cessation treatment (N=315).

RESULTS

Results demonstrated that elevated PTSS were associated with increased smoking to reduce negative affect and barriers to cessation, and that emotion dysregulation mediated these relationships.

CONCLUSION

These findings provide evidence of a mechanism between PTSS and psychological smoking maintenance factors, and suggest that emotion dysregulation may be a useful target for smoking cessation interventions among trauma-exposed individuals.

Posttraumatic stress symptoms and tobacco abstinence effects in a non-clinical sample: evaluating the mediating role of negative affect reduction smoking expectancies

The relation between posttraumatic stress symptoms and smoking is well documented but poorly understood. The present investigation sought to evaluate the impact of posttraumatic stress symptoms on subjective and behavioral tobacco abstinence effects both directly and indirectly through negative affect reduction smoking outcome expectancies. Participants included 275 (68.7% male; Mage =43.9, 10+ cig/day) adult non-treatment seeking smokers, who attended two counterbalanced laboratory sessions (16 h of smoking deprivation vs ad libitum smoking), during which they completed self-report measures of withdrawal symptoms and mood followed by a smoking lapse task in which they could earn money for delaying smoking and purchase cigarettes to smoke. Results supported a mediational pathway whereby higher baseline symptoms of posttraumatic stress predicted greater endorsement of expectancies that smoking will effectively reduce negative affect, which in turn predicted greater abstinence-provoked exacerbations in nicotine withdrawal symptoms and negative affect. Posttraumatic stress symptoms also predicted number of cigarettes purchased independent of negative affect reduction expectancies, but did not predict delaying smoking for money. Findings highlight tobacco abstinence effects as a putative mechanism underlying posttraumatic stress disorder (PTSD)-smoking comorbidity, indicate an important mediating role of beliefs for smoking-induced negative affect reduction, and shed light on integrated treatment approaches for these two conditions.

PTSD symptomatology and readiness to quit smoking among women with serious mental illness

INTRODUCTION

Posttraumatic stress disorder (PTSD) is a risk factor for tobacco addiction. The majority of research on PTSD and smoking has been conducted with men, particularly combat veterans, and little is known about the association among women. In a clinical sample of women civilian smokers with serious mental illness (SMI), we examined the prevalence of PTSD symptomatology and associations with physical and mental health functioning, co-occurring substance use, nicotine dependence, and readiness to quit smoking.

METHODS

376 adult women smokers aged 18-73 were recruited from 7 acute inpatient psychiatry units and screened by diagnostic interview for current PTSD symptomatology (PTSD(+)). In multiple regressions, we examined the associations of screening PTSD(+) with physical and mental health functioning; past-month drug use; past-year substance use disorders; nicotine dependence and readiness to quit smoking.

RESULTS

Nearly half the sample (43%) screened PTSD(+), which was significantly associated with the use of stimulants (OR=1.26) and opiates (OR=1.98), drug use disorders (OR=2.01), and poorer mental health (B=-2.78) but not physical health functioning. PTSD(+) status was unrelated to nicotine dependence, but predicted greater desire to quit smoking (B=2.13) and intention to stop smoking in the next month (OR=2.21). In multivariate models that adjusted for substance use disorders, physical and mental health functioning, and nicotine dependence, screening PTSD(+) remained predictive of greater desire and intention to quit smoking.

CONCLUSION

PTSD symptomatology was common in our sample of women smokers with SMI and associated with not only worse substance use and mental health, but also greater readiness to quit smoking, suggesting the need for and potential interest in integrative PTSD-addiction treatment among women.

Main and interactive effects of anxiety sensitivity and physical distress intolerance with regard to PTSD symptoms among trauma-exposed smokers

The present study examined the roles of anxiety sensitivity (AS; the tendency to misinterpret physical internal sensations of harmful) and distress tolerance (the capacity to tolerate aversive stimuli) in terms of the expression of posttraumatic stress disorder (PTSD) symptoms among a sample of trauma-exposed, treatment-seeking tobacco smokers (n = 137; Mage = 37.7 years, 48.2% female). It was hypothesized that higher AS and lower physical distress tolerance would interact to predict greater PTSD avoidance and hyperarousal symptoms. Results were partially consistent with this prediction. Specifically, there was a significant interactive effect of AS by physical distress tolerance in terms of PTSD hyperarousal symptom cluster severity. The form of the interaction was in the expected direction, with the highest levels of PTSD hyperarousal symptoms reported among smokers with higher levels of AS and a lower capacity to tolerate physical distress. Findings underscore the importance of considering AS and physical distress tolerance in terms of better understanding mechanisms underlying the expression of PTSD symptoms among trauma-exposed smokers.

Examining the relationships between posttraumatic stress disorder symptoms, positive smoking outcome expectancies, and cigarette smoking in people with substance use disorders: a multiple mediator model

Cigarette smoking is highly prevalent in people with substance use disorders (SUDs) and is associated with significant physical health problems. Posttraumatic stress disorder (PTSD) is also highly associated with both SUDs and cigarette smoking and may serve as a barrier to smoking cessation efforts. In addition, people with PTSD are more likely to hold positive smoking outcome expectancies (i.e., beliefs that smoking cigarettes results in positive outcomes); these beliefs may contribute to cigarette smoking in people with SUDs experiencing PTSD symptoms. The present study examined the relationship between PTSD symptoms and typical daily cigarette smoking/cigarette dependence symptoms in a sample of 227 trauma-exposed current smokers with SUDs (59.9% male, 89.4% Caucasian) seeking detoxification treatment services. Additionally, the indirect effects of multiple types of positive smoking outcome expectancies on these relationships were examined. Participants completed questionnaires assessing PTSD symptoms, positive smoking outcome expectancies, cigarette consumption, and cigarette dependence symptoms. Results indicated that PTSD symptoms were not directly related to cigarette consumption or cigarette dependence symptoms. However, negative affect reduction outcome expectancies were shown to have a significant indirect effect between PTSD symptoms and cigarette consumption, while negative affect reduction, boredom reduction, and taste-sensorimotor manipulation outcome expectancies were all found to have significant indirect effects between PTSD symptoms and cigarette dependence symptoms. The indirect effect involving negative affect reduction outcome expectancies was statistically larger than that of taste sensorimotor manipulation outcome expectancies, while negative affect reduction and boredom reduction outcome expectancies were comparable in magnitude. These results suggest that expectancies that smoking can manage negative affective experiences are related to cigarette smoking in people with SUDs experiencing PTSD symptoms and suggest that effective smoking cessation treatments should take into account these expectancies.

The prevalence of posttraumatic stress among women requesting induced abortion

Objectives

To describe the prevalence and pattern of traumatic experiences, to assess the prevalence of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS), to identify risk factors for PTSD and PTSS, and to analyse the association of PTSD and PTSS with concomitant anxiety and depressive symptoms in women requesting induced abortion.

Methods

A Swedish multi-centre study of women requesting an induced abortion. The Screen Questionnaire – Posttraumatic Stress Disorder was used for research diagnoses of PTSD and PTSS. Anxiety and depressive symptoms were evaluated by the Hospital Anxiety and Depression Scale (HADS).

Results

Of the 1514 respondents, almost half reported traumatic experiences. Lifetime- and point prevalence of PTSD were 7% (95% confidence interval [CI]: 5.8–8.5) and 4% (95% CI: 3.1–5.2), respectively. The prevalence of PTSS was 23% (95% CI: 21.1–25.4). Women who reported symptoms of anxiety or depression when requesting abortion were more likely to have ongoing PTSD or PTSS. Also single-living women and smokers displayed higher rates of ongoing PTSD.

Conclusions

Although PTSD is rare among women who request an induced abortion, a relatively high proportion suffers from PTSS. Abortion seeking women with trauma experiences and existing or preexisting mental disorders need more consideration and alertness when counselled for termination.

Transdermal nicotine during cue reactivity in adult smokers with and without anxiety disorders

Transdermal nicotine almost doubles tobacco cessation rates; however, little is known about what happens to smokers during the quit process when they are wearing the nicotine patch and are confronted with high-risk smoking triggers. This is particularly important for smokers with psychological disorders who disproportionately represent today's smokers and have more trouble quitting. Using a mixed between- and within-subjects design, smokers with anxiety disorders (n=61) and smokers without any current Axis I disorders (n=38) received transdermal nicotine (21 mg) or a placebo patch over two assessment days separated by 48 hr. Urge to smoke was evaluated during a 5-hr patch absorption period (reflecting general smoking deprivation) and during imaginal exposure to theoretically high-risk triggers containing smoking cues, anxiety cues, both, or neutral cues. No differences were observed between smokers with and without anxiety disorders. Significant Patch×Time and Patch×Cue Content interactions were found. Both patch conditions experienced an increase in urge during the deprivation period, but postabsorption urge was significantly higher in the placebo condition, suggesting that transdermal nicotine attenuated the degree to which urge to smoke increased over time. During the cue reactivity trials, when participants received the nicotine patch, they experienced significantly lower urge in response to both smoking-only and neutral cues, but not when anxiety cues were present (alone or in combination with smoking cues). These data suggest that transdermal nicotine alleviates urge only under certain circumstances and that adjunctive interventions are likely necessary to address smoking urges in response to spikes in distress among smokers trying to quit.

Panic attack history and anxiety sensitivity in relation to cognitive-based smoking processes among treatment-seeking daily smokers

INTRODUCTION

Empirical research has found that panic attacks are related to increased risk of more severe nicotine withdrawal and poor cessation outcome. Anxiety sensitivity (AS; fear of anxiety and related sensations) has similarly been found to be related to an increased risk of acute nicotine withdrawal and poorer cessation outcome. However, research has yet to examine the relative contributions of panic attacks and AS in terms of cognitive-based smoking processes (e.g., negative reinforcement smoking expectancies, addictive and negative affect-based reduction smoking motives, barriers to cessation, problem symptoms experienced while quitting).

METHOD

Participants (n = 242; 57.4% male; M (age) = 38.1) were daily smokers recruited as a part of a larger randomized control trial for smoking cessation. It was hypothesized that both panic attacks and AS would uniquely and independently predict the studied cognitive-based smoking processes.

RESULTS

As hypothesized, AS was uniquely and positively associated with all smoking processes after controlling for average number of cigarettes smoked per day, current Axis I diagnosis, and participant sex. However, panic attack history was only significantly related to problem symptoms experienced while quitting smoking.

CONCLUSIONS

Although past research has demonstrated significant associations between panic attacks and certain aspects of cigarette smoking (e.g., severity of nicotine withdrawal; lower abstinence rates, and negative affect reduction motives), the present findings suggest that AS may be more relevant to understanding beliefs about and motives for smoking behavior as well as perceptions of cessation-related difficulties.

Associations between posttraumatic stress disorder symptom clusters and cigarette smoking

Understanding the relationship between Posttraumatic stress disorder (PTSD) and cigarette smoking has been difficult because of PTSD's symptomatic heterogeneity. This study examined common and unique lifetime cross-sectional relationships between PTSD symptom clusters [Re-experiencing (intrusive thoughts and nightmares about the trauma), Avoidance (avoidance of trauma-associated memories or stimuli), Emotional Numbing (loss of interest, interpersonal detachment, restricted positive affect), and Hyperarousal (irritability, difficulty concentrating, hypervigilance, insomnia)] and three indicators of smoking behavior: (1) smoking status; (2) cigarettes per day; and (3) nicotine dependence. Participants were adult respondents in the National Epidemiologic Survey of Alcohol and Related Conditions with a trauma history (n = 23,635). All four symptom clusters associated with each smoking outcome in single-predictor models (ps <. 0001). In multivariate models including all of the symptom clusters as simultaneous predictors, Emotional Numbing was the only cluster to retain a significant association with lifetime smoking over and above the other clusters, demographics, and Axis-I comorbidity (OR = 1.30, p < .01). While Avoidance uniquely associated with smoking status and nicotine dependence in multivariate models, these relations fell below significance after adjusting for demographics and comorbidity. No clusters uniquely associated with cigarettes per day. Hyperarousal uniquely related with nicotine dependence over and above the other clusters, demographics, and Axis-I comorbidity (OR = 1.51, p < .001). These results suggest the following: (a) common variance across PTSD symptom clusters contribute to PTSD's linkage with smoking in the American population; and (b) certain PTSD symptom clusters may uniquely associate with particular indicators of smoking behavior. These findings may clarify the underpinnings of PTSD-smoking comorbidity and inform smoking interventions for trauma-exposed individuals.

Smoking outcome expectancies in military veteran smokers with posttraumatic stress disorder

INTRODUCTION

Smoking outcome expectancies were investigated in treatment-seeking military Veteran smokers with posttraumatic stress disorder (PTSD). The investigation of smoking outcome expectancies may enhance our understanding of the relationship between PTSD and cigarette smoking.

METHODS

Participants were 943 military Veterans with a diagnosis of PTSD who were current smokers enrolled in a randomized multisite effectiveness trial to test whether the integration of smoking cessation treatment into mental health care (integrated care) improves prolonged abstinence rates compared with referral to specialized smoking cessation clinics (usual care). Using confirmatory factor analysis (CFA), we evaluated the conceptual model of smoking outcome expectancies measured on the Smoking Consequences Questionnaire-Adult (SCQ-A) version. The Kraemer method of mediation analysis was used to investigate the role of smoking outcome expectancies in mediating relationships between PTSD symptoms and smoking behavior, tobacco dependence, and abstinence self-efficacy.

RESULTS

The CFA supported the 10-factor structure of the SCQ-A in smokers with PTSD. Relationships between measures of PTSD symptoms and tobacco dependence were mediated by the smoking outcome expectancy regarding negative affect reduction. This same smoking outcome expectancy mediated relationships between PTSD symptoms and smoking abstinence self-efficacy.

CONCLUSIONS

The findings support the use of the SCQ-A as a valid measure of smoking outcome expectancies in military Veteran smokers with PTSD. Moreover, they suggest that smoking outcome expectancies may play an important role in explaining the relationship between PTSD and cigarette smoking.

The role of smoking expectancies in the relationship between PTSD symptoms and smoking behavior among women exposed to intimate partner violence

Intimate partner violence (IPV) is a public health problem associated with negative health consequences, including higher rates of tobacco smoking. Smoking expectancies are related to motivation to quit and relapse. IPV-exposed women endorse higher rates of PTSD symptoms, which are related to smoking and smoking expectancies. The present study sought to examine the relationship among smoking behavior, smoking expectancies, and PTSD symptoms among IPV-exposed women. Participants were 83 women who reported experiencing IPV within the last month, smoked an average of 12 cigarettes per day, and reported moderate levels of nicotine dependence (FTND mean=4.4). Participants completed baseline and follow-up interviews. Multiple regression analyses assessed the relationships among smoking expectancies and PTSD symptoms to cigarettes smoked per day and nicotine dependence. Findings demonstrated that Stimulation/State Enhancement expectancies were positively related to cigarettes per day, whereas PTSD arousal symptoms were negatively related to cigarettes per day, p's<.05. Neither smoking expectancies nor PTSD symptoms were significantly related to nicotine dependence. Supplemental analyses revealed that PTSD re-experiencing symptoms were negatively related and PTSD avoidance/numbing symptoms were positively related to Stimulation/State Enhancement expectancies, p's<.05. This study extends findings regarding the association between PTSD symptoms and smoking among an understudied population - IPV-exposed women. The relationship between PTSD symptoms and smoking differed across PTSD symptom clusters and expectancy scales, which may have implications for treatment development. The fact that expectancies and PTSD symptoms are related to smoking behavior among IPV-exposed women may be important for enhancing prevention and intervention efforts.

Cotinine enhances the extinction of contextual fear memory and reduces anxiety after fear conditioning

Posttraumatic stress disorder (PTSD) is an anxiety disorder triggered by traumatic events. Symptoms include anxiety, depression and deficits in fear memory extinction (FE). PTSD patients show a higher prevalence of cigarette smoking than the general population. The present study investigated the effects of cotinine, a tobacco-derived compound, over anxiety and contextual fear memory after fear conditioning (FC) in mice, a model for inducing PTSD-like symptoms. Two-month-old C57BL/6J mice were separated into three experimental groups. These groups were used to investigate the effect of pretreatment with cotinine on contextual fear memory and posttreatment on extinction and stability or retrievability of the fear memory. Also, changes induced by cotinine on the expression of extracellular signal-regulated kinase (ERK)1/2 were assessed after extinction in the hippocampus. An increase in anxiety and corticosterone levels were found after fear conditioning. Cotinine did not affect corticosterone levels but enhanced the extinction of contextual fear, decreased anxiety and the stability and/or retrievability of contextual fear memory. Cotinine-treated mice showed higher levels of the active forms of ERK1/2 than vehicle-treated mice after FC. This evidence suggests that cotinine is a potential new pharmacological treatment to reduce symptoms in individuals with PTSD.

A prospective examination of the relationships between PTSD, exposure to assaultive violence, and cigarette smoking among a national sample of adolescents

Research demonstrates robust associations among posttraumatic stress disorder (PTSD), exposure to assaultive violence (i.e., sexual assault, physical assault, and witnessed violence), and cigarette smoking among adults and adolescents. Whether exposure to assaultive violence confers risk for cigarette smoking over and above the effects of PTSD and non-assaultive traumatic events (e.g., motor vehicle accidents) is unclear. The current study prospectively measured PTSD, assaultive violence exposure, non-assaultive traumatic event exposure, and cigarette smoking three times over approximately three years among a nationally representative sample of adolescents (N=3614, age range 12-17 at Wave 1). Results revealed that multiple exposure to assaultive violence at Wave 1 was a consistent and robust prospective predictor of cigarette smoking at Waves 2 and 3. By contrast, PTSD diagnoses and non-assaultive traumatic event exposures at Wave 1 only predicted cigarette smoking at Wave 2, but not at Wave 3. Theoretical and clinical implications are discussed.

The relationship between posttraumatic stress disorder and smoking outcome expectancies among U.S. military veterans who served since September 11, 2001

Posttraumatic stress disorder (PTSD) is associated with increased rates of smoking although little is known regarding the mechanisms underlying this relationship. The current study examined expectations about smoking outcomes among smokers with and without PTSD. The sample included 96 veterans (mean age of 34 years) and included 17% women and 50% racial minorities. Smoking expectancies were measured with the Smoking Consequences Questionnaire-Adult (Copeland, Brandon, & Quinn, 1995). Consistent with previous work suggesting that smokers with PTSD smoke in an effort to reduce negative affect, unadjusted analyses indicated that smokers with PTSD (n = 38) had higher expectations that smoking reduces negative affect than smokers without PTSD (d = 0.61). Smokers with PTSD also had increased expectancies associated with boredom reduction (d = 0.48), stimulation (d = 0.61), taste/sensorimotor manipulation aspects of smoking (d = 0.73), and social facilitation (d = 0.61). Results of hierarchical linear regression analyses indicated that PTSD symptom severity was uniquely associated with these expectancies beyond the effects of gender and nicotine dependence. More positive beliefs about the consequences of smoking may increase risk of continued smoking among those with PTSD who smoke. Further understanding of smoking expectancies in this group may help in developing interventions tailored for this vulnerable population.

Posttraumatic stress and marijuana use coping motives: the mediating role of distress tolerance

The present investigation examined the explanatory (i.e,. mediating) role of distress tolerance (DT) in the relation between posttraumatic stress (PTS) symptom severity and marijuana use coping motives. The sample consisted of 142 adults (46.5% women; M(age) = 22.18, SD = 7.22, range = 18-55), who endorsed exposure to at least one Criterion A traumatic life event (DSM-IV-TR, 2000) and reported marijuana use within the past 30 days. As predicted, results demonstrated that DT partially mediated the relation between PTS symptom severity and coping-oriented marijuana use. These preliminary results suggest that DT may be an important cognitive-affective mechanism underlying the PTS-marijuana use coping motives association. Theoretically, trauma-exposed marijuana users with greater PTS symptom severity may use marijuana to cope with negative mood states, at least partially because of a lower perceived capacity to withstand emotional distress.

Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial

CONTEXT

Most smokers with mental illness do not receive tobacco cessation treatment.

OBJECTIVE

To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.

DESIGN, SETTING, AND PATIENTS

A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009.

INTERVENTION

Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.

MAIN OUTCOME MEASURES

Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.

RESULTS

Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.

CONCLUSION

Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118534.

Cigarette smoking and advice to quit in a national sample of homeless adults

BACKGROUND

Cigarette smoking is common among homeless people, but its characteristics in this vulnerable population have not been studied at a national level. Whether homeless smokers receive advice to quit from healthcare providers is also unknown.

PURPOSE

To determine the prevalence and predictors of current cigarette smoking, smoking cessation, and receipt of clinician advice to quit in a national sample of homeless adults.

METHODS

This study analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, representing more than 436,000 people nationally. Using multivariable logistic regression, the independent predictors of smoking, quitting, and receiving advice to quit were identified. Analyses were conducted in 2008-2009.

RESULTS

The prevalence of current smoking was 73%. The lifetime quit rate among ever smokers was 9%. Among past-year smokers, 54% reported receiving clinician advice to quit. Factors independently associated with current smoking included out-of-home placement in childhood (AOR=2.79, 95% CI=1.03, 7.52); victimization while homeless (AOR=2.36, 95% CI=1.15, 4.83); past-year employment (AOR=2.52, 95% CI=1.13, 5.58); and prior illicit drug use (AOR=7.21, 95% CI=3.11, 16.7) or problem alcohol use (AOR=7.42, 95% CI=2.51, 21.9). Respondents with multiple homeless episodes had higher odds of receiving quit advice (AOR=2.51, 95% CI=1.30, 4.83) but lower odds of quitting (AOR=0.47, 95% CI=0.29, 0.78).

CONCLUSIONS

Compared to the general population, homeless people are far more likely to smoke and much less likely to quit, even though more than half of smokers received quit advice in the past year. Interventions for homeless smokers should address the unique comorbidities and vulnerabilities of this population.

Unique Patterns of Substance Misuse associated with PTSD, Depression, and Social Phobia

OBJECTIVES: This study investigated the relations between post-trauma psychopathology and substance abuse in a sample of trauma-exposed college students (n = 136) assigned to four groups based on primary diagnosis: posttraumatic stress disorder, depression, social phobia, or well-adjusted (participants who had low levels of distress). Groups were compared on a series of dimensions of substance use/abuse. RESULTS: Participants in the PTSD group evidenced greater substance use and abuse than those in the social phobia and well-adjusted groups on several dimensions and greater alcohol consumption than the depressed group. Correlation analyses suggested that most dimensions of substance abuse were related more strongly to avoidance and numbing (cluster C) symptoms than to reexperiencing and hyperarousal. CONCLUSIONS: The present findings suggest that trauma-related psychopathology may be associated with a more hazardous pattern of substance use than depression and social phobia.

Temporal relations between sleep problems and both traumatic event exposure and PTSD: a critical review of the empirical literature

There has been growing interest in the interrelations among traumatic event exposure, posttraumatic stress disorder (PTSD), and sleep problems. A wealth of research has examined the associations among these factors and there is an emerging literature focused on how sleep problems relate to both traumatic event exposure and PTSD across time. The current review provides a detailed analysis of studies pertaining to the temporal patterning of sleep problems and traumatic event-related factors (e.g., traumatic event exposure, PTSD) and draws conclusions regarding the current state of this literature. Research coalesces to suggest (1) exposure to a traumatic event can interfere with sleep, (2) PTSD is related to the development of self-reported sleep problems, but evidence is less clear regarding objective indices of sleep, and (3) limited evidence suggests sleep problems may interfere with recovery from elevated posttraumatic stress levels. Future research now needs to focus on understanding mechanisms involved in these patterns to inform the prevention and treatment of comorbid sleep problems and PTSD.

Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure

This article explores the psychosocial and social-structural vulnerability in relation to women's tobacco use, smoke exposure and responses to policy, and examines these issues in the context of women's lives and roles, describing forward looking strategies that could improve research and equity in outcomes for women. Various literatures on smoking among women and girls, and how women and sub-populations of women respond to tobacco control policies are reviewed. Specific sub-populations exhibiting more tobacco use and exposure are described, such as young pregnant and mothering women and low-income women. Emerging evidence also reveals links between smoking and experiences such as childhood sexual abuse, interpersonal violence, post-traumatic stress disorder, mental health issues and alcohol and drug dependence. Varied sub-populations of women respond in different ways to price and taxation, sales restrictions and location restrictions. However, tobacco control policies have, to date, been fashioned as broad instruments, not taking into account social context, trauma backgrounds, gendered roles such as mothering, unequal power relations affecting women in relationships and workplaces, and differences in access to resources and social support. When these issues are considered, the implications for tobacco policy development include: widening the policy purview, accounting for uneven and differential responses to policies, committing to an ethical framework, extending sex, gender and diversity based analyses, and improving research methods and approaches.

Test of the role of nicotine dependence in the relation between posttraumatic stress disorder and panic spectrum problems

Posttraumatic stress disorder (PTSD) frequently co-occurs with panic spectrum problems. Relatively little empirical work has tested possible mechanisms accounting for this association. Nicotine dependence often ensues subsequent to PTSD onset and research suggests smoking high numbers of cigarettes daily may lead to panic problems. The current study tested the hypotheses that nicotine dependence partially mediates the relations between PTSD and both panic attacks and panic disorder within a nationally representative sample of 5,692 (3,020 women; M(Age) = 45, SD = 18) adults from the National Comorbidity Survey-Replication. Results were consistent with hypotheses. These findings support the theory suggesting smoking among people with PTSD may be involved in the development of panic problems.

Trauma exposure influences cue elicited affective responses among smokers with and without a history of major depression

The current study tested the emotional reactivity of smokers with and without histories of major depression (MDD Hx) and trauma exposure (TE). Four counterbalanced conditions nested negative (e.g., dysphoric) or neutral mood inductions with in vivo versus control smoking paraphernalia cues (Neutral+Control; Neutral+Cigarette; Neg+Control; Neg+Cigarette). Mixed model analysis of covariance (ANCOVA) tested between and within subjects differences in negative affective symptoms pre- to post-exposure across four groups (TE+MDD Hx; TE only; MDD Hx only; no history). Results produced two notable effects. First, TE only individuals endorsed the greatest increase in depressive symptoms across both negative mood induction conditions (regardless of smoking paraphernalia) compared with other groups. Second, dual history participants (TE+MDD Hx) show a potentiated depressive response to the Neg+Cigarette condition compared with the Neg+Control condition. Implications to a depression-specific negative affective vulnerability among TE only smokers that is independent of MDD Hx and greater than smokers with a MDD Hx are discussed.

Relationship between PTSD symptomatology and nicotine dependence severity in crime victims

Smoking rates are higher and cessation rates are lower among individuals with posttraumatic stress disorder (PTSD) compared to the general population, thus understanding the relationship between PTSD and nicotine dependence is important. In a sample of 213 participants with a crime-related trauma (109 with PTSD), the relationship between PTSD status, smoking status (smoker vs. non-smoker), substance abuse diagnosis (SUD), PTSD symptoms, and sex was assessed. SUD diagnosis was significantly related to smoking status, but PTSD symptomatology and sex were not. Among smokers (n=117), increased nicotine dependence severity was associated with being male and with increased level of PTSD avoidance symptoms. Correlations indicated that PTSD avoidance and hyperarousal symptom clusters and total PTSD symptom scores were significantly related to nicotine dependence severity in males, while PTSD symptomatology in general did not correlate with dependence severity for females. The results suggest that level of PTSD symptomatology, particularly avoidance symptoms, may be important targets for smoking cessation treatment among male smokers who have experienced a traumatic event.

Evaluation of smoking characteristics among community-recruited daily smokers with and without posttraumatic stress disorder and panic psychopathology

The present investigation compared 123 community-recruited daily smokers with posttraumatic stress disorder (PTSD), panic disorder (PD), nonclinical panic attacks (PA), or no current Axis I psychopathology (controls; C) in terms of nicotine dependence, smoking rate, quit history, severity of symptoms during past quit attempts, and motivation for and expectancies about smoking. No differences were observed between groups in regard to smoking rate or nicotine dependence. The PTSD group reported making more lifetime quit attempts than the other groups, and the PTSD and PD groups perceived more severe symptoms during past quit attempts. The PD and PTSD groups reported greater motivation to smoke to reduce negative affect. Individuals with PTSD endorsed a stronger expectation that smoking would alleviate negative mood states and would produce negative consequences. Overall, results suggest that smokers with PD or PTSD differ from other smoking groups in a number of clinically significant ways.

Smoking, traumatic event exposure, and post-traumatic stress: a critical review of the empirical literature

The current review critically examines the extant empirical literature focused on the associations among cigarette smoking, trauma, and post-traumatic stress. Inspection of the extant literature suggests that smoking rates are significantly higher among persons exposed to a traumatic event relative to those without such exposure. Moreover, smoking rates appear particularly high among persons with post-traumatic stress disorder (PTSD). In terms of the direction of this relation, evidence most clearly suggests that post-traumatic stress is involved in the development of smoking. Significantly less is known about the role of trauma and PTSD in terms of cessation outcome. Limitations of extant work, clinical implications, and key directions for future study are delineated.