Effect of transdermal nicotine patches on cigarette smoking: a double blind crossover study

The impact of vaping ethanol-containing electronic cigarette liquids on roadside impairment investigations

Legal professionals and others have suggested that vaping electronic cigarettes (e-cigs) prior to or during ethanol breath testing may produce false positives. Preliminary breath tests (PBTs) and evidentiary breath tests (EBTs) measure ethanol in exhaled breath and standardized field sobriety tests (SFSTs) are used to assess impairment. Ethanol has been identified in e-cig liquids (e-liquids). Presented are a series of experiments designed to determine the mechanics of vaping ethanol using an e-cig and the effects of vaping ethanol on the SFSTs and breath tests used by law enforcement officers (LEO). Twelve participants (five females, age: 21-32 and seven males, age: 21-55), vaped either one or ten puffs of an e-liquid (0% or 20% ethanol). LEOs assessed impairment using SFSTs (12 and 42 min), PBTs (<1, 27, 32, 37 and 57 min) and EBTs (2, 29, 34, 39 and 59 min) post-vaping. A self-assessment test was administered post-vaping (22 and 52 min). Baseline responses for all measures were collected prior to vaping. Results demonstrated that ethanol in the e-liquids was aerosolized by e-cigs and produced particles that could reach the deep lung tissue based on mean-mass diameter. Ethanol was detected by PBT <3 min after participants vaped one (0.007-0.030 g/210 L) or ten puffs (013-0.074 g/210 L) of a 20% ethanol e-liquid. Ethanol was not detected by PBT at any subsequent time point. Ethanol was not detected by the EBT under any condition. Impairment was not indicated by the SFST. Some subjective effects were reported, but few statistically significant differences between conditions were indicated. A wait period prior to ethanol breath testing is not always mandated, depending on jurisdiction, or observed in all applications, such as workplace testing. The results demonstrate that a wait period must be employed to prevent vaping-related false-positive breath ethanol results.

Preliminary assessment of the subjective effects of electronic-cigarettes in young-adult low-dose electronic-cigarette users: Effects of nicotine dose and e-liquid flavor

OBJECTIVE

The present study evaluated the effects of nicotine concentration (0-10 mg/ml) and flavor (gummy bear vs unflavored) on the subjective experiences of vaporized nicotine in young adult low-dose nicotine (3 mg/ml) ECIG users.

PARTICIPANTS

Eight young adult ECIG users were recruited.

METHODS

A single blinded crossover study was used. Participants were instructed to take ten 1.5 second puffs, each separated by 20 seconds. After self-administration, heart rate was recorded, and participants completed the Drug Effects, Direct Effects of Nicotine, and Direct Effects of ECIG questionnaires.

RESULTS

ECIG user's standard daily nicotine dose influenced the rewarding and aversive effects of nicotine as the 10 mg/ml dose was found to be aversive in this user group. The combination of flavor and nicotine increased the subjective effects of ECIGs.

CONCLUSIONS

Flavored e-liquids contribute to the reinforcing properties of nicotine by enhancing the subjective effects, which may lead to continued ECIG use.

Pilot randomized controlled trial evaluating the effect of random nicotine delivery on cigarettes per day and smoke exposure

BACKGROUND

Many smokers report attempting to quit each year, yet most relapse, in part due to exposure to smoking-related cues. It is hypothesized that extinction of the cue-drug association could be facilitated through random nicotine delivery (RND), thus making it easier for smokers to quit. The current study aimed to evaluate the effects of RND on smoking cessation-related outcomes including cigarettes per day (CPD) and exhaled carbon monoxide (CO).

METHODS

Participants were current smokers (>9 CPD) interested in quitting. Novel trans-mucosal, orally dissolving nicotine films, developed by Bionex Pharmaceuticals, were used in the study. The pharmacokinetic profile of these films was assessed in single (Experiment 1) and multiple-dose (Experiment 2) administrations prior to the smoking cessation study (Experiment 3). In Experiment 3, participants were randomized 1:1:1 to recieve 4 nicotine films per day of either: placebo delivery (0 mg), steady-state delivery (2 mg), or random nicotine delivery (RND) (0 mg or 4 mg). After two weeks, participants were advised to quit (target quit date, TQD) and were followed up 4 weeks later to collect CPD and CO and to measure dependence (Penn State Cigarette Dependence Index; PSCDI) and craving (Questionnaire of Smoking Urges; QSU-Brief). Means and frequencies were used to describe the data and repeated measures ANOVA was used to determine differences between groups.

RESULTS

The pharmacokinetic studies (Experiment 1 and 2) demonstrated that the films designed for this study delivered nicotine as expected, with the 4 mg film delivering a nicotine boost of approximately 12.4 ng/mL across both the single and the multiple dose administration studies. The films reduced craving for a cigarette and were well-tolerated, overall, and caused no changes in blood pressure or heart rate. Using these films in the cessation study (Experiment 3) (n = 45), there was a significant overall reduction in cigarettes smoked per day (CPD) and in exhaled CO, with no significant differences across groups (placebo, steady-state, RND). In addition, there were no group differences in dependence or craving. Adverse events included heartburn, hiccups, nausea, and to a lesser extent, vomiting and anxiety and there were no differences across groups.

CONCLUSION

Overall, this pilot study found that RND via orally dissolving films was feasible and well tolerated by participants. However, RND participants did not experience a greater reduction in self-reported CPD and exhaled CO, compared with participants in the steady-state and placebo delivery groups. Future studies to evaluate optimal RND parameters with larger sample sizes are needed to fully understand the effect of RND on smoking cessation-related outcomes.

Tobacco Use Disorder

Tobacco use disorder is highly prevalent; more than a billion individuals use tobacco worldwide. Popular views on the addictive potential of tobacco often underestimate the complex neural adaptations that underpin continued use. Although sometimes trivialized as a minor substance, effects of nicotine on behavior lead to profound morbidity over a lifetime of exposure. Innovations in processing have led to potent forms of tobacco and delivery devices. Proactive treatment strategies focus on pharmacotherapeutic interventions. Innovations on the horizon hold promise to help clinicians address this problem in a phenotypically tailored manner. Efforts are needed to prevent tobacco use for future generations.

Abuse liability of electronic cigarettes in men who are experienced electronic cigarette users

Most electronic cigarettes (e-cigs) aerosolize a nicotine-containing liquid that users inhale. Few experimental studies have examined e-cig abuse liability (the extent to which use of these products may lead to persistent and/or problematic use). In this study, 24 experienced male e-cig users completed 4 sessions that differed byproduct used: own e-cig (OWN), an eGo e-cig filled with participants' own brand/flavor liquid in 0 mg/mL nicotine (e-cig0), an eGo e-cig filled with the highest nicotine concentration available in participants' own brand/flavor (e-cighighest), and a U.S. Food and Drug Administration-approved nicotine inhaler (IN). Outcome measures included crossover point on the multiple-choice procedure, plasma nicotine delivery, and subjective effect profile. After 10 puffs, a significantly higher mean crossover point was observed for OWN at $1.35 (SD = 0.90) compared to e-cighighest at $0.88 (SD = 0.89), e-cig0 at $0.83 (SD = 0.79), and IN at $0.72 (SD = 0.84). Significant increases in mean plasma nicotine concentration were observed for OWN at 7.94 ng/mL (SD = 6.19) and e-cighighest at 7.51 ng/mL (SD = 5.39). Significant reductions in abstinence symptom suppression and higher ratings of satisfaction were observed for OWN and e-cighighest, with significantly less suppression and lower ratings of satisfaction for e-cig0 and IN. These findings suggest that human laboratory methods can be used to assess e-cig abuse liability and that nicotine-containing e-cigs have greater abuse liability than nicotine-free e-cigs and the IN. Potential regulations intended to limit e-cig abuse liability should be tested using these or similar procedures. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Abuse liability assessment of an electronic cigarette in combustible cigarette smokers

Under certain conditions, electronic cigarettes (e-cigs) can deliver nicotine to and suppress tobacco abstinence symptoms in cigarette smokers. Growing popularity of e-cigs raises abuse liability concerns. This study's purpose was to compare the abuse liability of an e-cig (1.5 Ohm, 3.3 V) filled with 36 mg/mL or 0 mg/mL nicotine to an Food and Drug Administration (FDA)-approved nicotine inhaler (IN) and participants' own brand (OB) of cigarettes. Smokers (N = 24) completed four sessions in which they completed the multiple-choice procedure, and plasma nicotine concentration and subjective effects were measured. Mean (SD) multiple-choice procedure crossover point was $0.87 (1.0) for the 36-mg/mL nicotine e-cig and $0.96 (1.2) for the 0-mg/mL e-cig, significantly higher than the IN mean of $0.32 (0.6) but significantly lower than the OB cigarette mean of $1.42 (1.4). Ten puffs from an own-brand cigarette increased mean plasma nicotine concentration from 3.55 (2.8) to 13.64 (9.8) ng/mL, as compared to an increase from 3.16 (1.8) to 8.51 (5.4) ng/mL for the 36-mg/mL e-cig. The 36-mg/mL e-cig reduced nicotine abstinence symptoms more than the 0-mg/mL e-cig, and both e-cigs were rated as more reinforcing than the inhaler but less reinforcing than participants' OB cigarettes (ps < .05). Results suggest that the e-cig examined had higher abuse liability than the IN but lower than combustible cigarettes. These data and methods may be useful for policymakers by revealing how e-cig abuse liability compares to tobacco/nicotine products with abuse liability profiles that are well established. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Estimation of compliance with exclusive smoking of very low nicotine content cigarettes using plasma cotinine

Regulations requiring a reduction of the nicotine content in cigarettes to minimally addictive levels could significantly reduce the public health impact of cigarette smoking. Clinical trials evaluating this strategy are ongoing and methods have been developed to use nicotine biomarkers to estimate compliance with use of very low nicotine content cigarettes (VLNCs). To date, these methods have not considered the potential contribution of nicotine absorption from environmental tobacco smoke (ETS) among research participants. This study used data from 100 randomly selected study completers in ongoing clinical trials of VLNCs (50 randomized to Usual Nicotine Content Cigarettes (UNCs) and 50 to VLNCs) to assess the use of plasma cotinine to estimate compliance. Plasma cotinine and smoking behavior were recorded at baseline after 2 weeks smoking UNC cigarettes, and then after 18 weeks of either continuing smoking UNCs or reducing the nicotine content such that the last 6 weeks comprised smoking VLNCs. Plasma cotinine remained stable (267 ng/ml) in the UNC group but reduced to 93 ng/ml in the VLNC group (p < 0.01). Compliance with smoking VLNCs was first estimated by comparing the cotinine per cigarette on VLNCs with UNCs after allowing for potential compensatory smoking. We found that 29 (58%) of the VLNC group were compliant. Adjusting for potential ETS exposure estimated 32 (64%) to be compliant. This latter group (n = 32) had a mean plasma cotinine on VLNCs of 7 ng/ml (range = 3-16.4 ng/ml). Adjusting for potential ETS exposure may improve identification of participants who plausibly complied with exclusive VLNC use.

Triangulating abuse liability assessment for flavoured cigar products using physiological, behavioural economic and subjective assessments: a within-subjects clinical laboratory protocol

INTRODUCTION

In the USA, Food and Drug Administration regulations prohibit the sale of flavoured cigarettes, with menthol being the exception. However, the manufacture, advertisement and sale of flavoured cigar products are permitted. Such flavourings influence positive perceptions of tobacco products and are linked to increased use. Flavourings may mask the taste of tobacco and enhance smoke inhalation, influencing toxicant exposure and abuse liability among novice tobacco users. Using clinical laboratory methods, this study investigates how flavour availability affects measures of abuse liability in young adult cigarette smokers. The specific aims are to evaluate the effect of cigar flavours on nicotine exposure, and behavioural and subjective measures of abuse liability.

METHODS AND ANALYSES

Participants (projected n=25) are healthy smokers of five or more cigarettes per day over the past 3 months, 18-25 years old, naive to cigar use (lifetime use of 50 or fewer cigar products and no more than 10 cigars smoked in the past 30 days) and without a desire to quit cigarette smoking in the next 30 days. Participants complete five laboratory sessions in a Latin square design with either their own brand cigarette or a session-specific Black & Mild cigar differing in flavour (apple, cream, original and wine). Participants are single-blinded to cigar flavours. Each session consists of two 10-puff smoking bouts (30 s interpuff interval) separated by 1 hour. Primary outcomes include saliva nicotine concentration, behavioural economic task performance and response to various questionnaire items assessing subjective effects predictive of abuse liability. Differences in outcomes across own brand cigarette and flavoured cigar conditions will be tested using linear mixed models.

ETHICS AND DISSEMINATION

The Virginia Commonwealth University Institutional Review Board approved the study (VCU IRB: HM20007848). Dissemination channels for study findings include scientific journals, scientific meetings, and policy briefs.

TRIAL REGISTRATION NUMBER

NCT02937051.

Effects of electronic cigarette liquid solvents propylene glycol and vegetable glycerin on user nicotine delivery, heart rate, subjective effects, and puff topography

BACKGROUND

Electronic cigarettes (ECIGs) are a class of tobacco products that produce different effects (e.g., nicotine delivery), depending on the device, liquid, and behavioral factors. However, the influence of the two primary ECIG liquid solvents, propylene glycol (PG) and vegetable glycerin (VG), on ECIG acute effects is unknown.

METHODS

Thirty ECIG-experienced, ≥12-h nicotine- abstinent participants completed four conditions consisting of two ECIG-use bouts (10 puffs, 30 s interpuff-interval) differing only by liquid PG:VG ratio (2PG:98VG, 20PG:80VG, 55PG:45VG, 100PG). Device power (7.3 W) and liquid nicotine concentration (18 mg/ml) remained constant. Nicotine delivery, subjective effects, heart rate (HR), and puff topography were assessed.

RESULTS

In the 100PG condition, participants took shorter and smaller puffs but obtained significantly more nicotine relative to the two VG-based conditions. Total nicotine exposure (i.e., area under the curve) was also significantly higher during use of the two PG-based liquids. However, participants reported that the 100 PG liquid was significantly less "pleasant" and "satisfying" relative to the other liquids (all ps < .05). Increases in HR and decreases in abstinence symptoms (e.g., "craving") did not differ across conditions.

CONCLUSIONS

PG:VG ratio influenced nicotine delivery, some subjective effects, and puff topography. Lower overall product satisfaction associated with the 100PG liquid suggests factors other than nicotine delivery (e.g., aerosol visibility) may play a role in maintaining ECIG use. Regulating ECIG acute effects such as nicotine delivery and subjective effects may require simultaneous attention to liquid PG:VG ratio as well as device, liquid, and behavioral factors known to influence these outcomes.

Acceptability of SPECTRUM Research Cigarettes among Participants in Trials of Reduced Nicotine Content Cigarettes

Objectives

SPECTRUM research cigarettes (SPECTRUMs) are being used in trials evaluating the effects of switching to reduced nicotine content (RNC) cigarettes. Because smokers have a high brand affinity, we evaluated if they were willing to switch and continue smoking normal nicotine content (NNC) SPECTRUMs.

Methods

We asked smokers (N = 341) to rate their own brand of cigarettes and NNC SPECTRUMs (after 2 weeks of use) using subjective measures including satisfaction, reward, taste, and craving reduction. We measured plasma cotinine, exhaled carbon monoxide (CO), and cigarettes per day (CPD), and recorded reasons for dropping out.

Results

After 2 weeks, 95% of participants chose to continue using SPECTRUMs for an additional 18 weeks. Moreover, 67% said SPECTRUMs were as good as or better than their own brand, and 65% said they would consider purchasing them. Ratings of satisfaction, reward, and craving reduction were 10%-15% lower on SPECTRUMs than on their own brand (p < .01). There were no differences in these ratings between menthol and non-menthol smokers.

Conclusions

Menthol and non-menthol SPECTRUMs are acceptable to smokers. Lower SPECTRUM ratings were likely due to brand switching and did not hinder study retention.

Electronic cigarette user plasma nicotine concentration, puff topography, heart rate, and subjective effects: Influence of liquid nicotine concentration and user experience

Electronic cigarette (ECIG) nicotine delivery and other effects may depend on liquid nicotine concentration and user experience. This study is the first to systematically examine the influence of ECIG liquid nicotine concentration and user experience on nicotine delivery, heart rate, puff topography, and subjective effects. Thirty-three ECIG-experienced individuals and 31 ECIG-naïve cigarette smokers completed 4 laboratory conditions consisting of 2, 10-puff bouts (30-sec interpuff interval) with a 3.3-V ECIG battery attached to a 1.5-Ω "cartomizer" (7.3 W) filled with 1 ml ECIG liquid. Conditions differed by liquid nicotine concentration: 0, 8, 18, or 36 mg/ml. Participants' plasma nicotine concentration was directly related to liquid nicotine concentration and dependent on user experience, with significantly higher mean plasma nicotine increases observed in ECIG-experienced individuals relative to ECIG-naïve smokers in each active nicotine condition. When using 36 mg/ml, mean plasma nicotine increase for ECIG-experienced individuals was 17.9 ng/ml (SD = 17.2) and 6.9 (SD = 7.1; p < .05) for ECIG-naïve individuals. Between-group differences were likely due to longer puffs taken by experienced ECIG users: collapsed across condition, mean puff duration was 5.6 sec (SD = 3.0) for ECIG-experienced and 2.9 (SD = 1.5) for ECIG-naïve individuals. ECIG use also suppressed nicotine/tobacco abstinence symptoms in both groups; the magnitude of abstinence symptom suppression depended on liquid nicotine concentration and user experience. These and other recent results suggest that policies intended to limit ECIG nicotine delivery will need to account for factors in addition to liquid nicotine concentration (e.g., device power and user behavior). (PsycINFO Database Record

The effect of varenicline and nicotine patch on smoking rate and satisfaction with smoking: an examination of the mechanism of action of two pre-quit pharmacotherapies

OBJECTIVES

In recent years, there has been growing research interest in using nicotine replacement medications to aid smoking reduction prior to a quit attempt. Gaining a better understanding of how treatments influence smoking reduction may allow for better tailoring of treatments and, ultimately, better cessation outcomes. The objective of the current study was to test the effects of the pre-quit use of varenicline and nicotine patch on smoking rate and satisfaction with smoking.

METHODS

All participants were required to attend up to five study visit sections. Participants (n = 213) who were interested in quitting were randomised (open-label) to receive either pre-quit patch or varenicline (both treatments started 2 weeks prior to an assigned quit day, followed by 10 weeks post-quit) or standard patch (10 weeks starting from an assigned quit day). Participants used modified smartphones to monitor their smoking in real time for 4 weeks.

RESULTS

Participants in the two pre-quit treatment groups reported significant reductions in both their satisfaction with smoking (p < 0.001) and smoking rate (p < 0.001) from baseline to the end of pre-quit period; participants in the standard patch group did not. The observed reduction of smoking rate was associated with the satisfaction with smoking (p < 0.01), although the mediation effect of satisfaction was small.

CONCLUSIONS

Pre-quit treatment caused reductions in satisfaction with smoking and smoking rate. Satisfaction was associated with changes in smoking rate, but the relationship was weak. As such, monitoring reductions in satisfaction do not appear to be a viable method of evaluating responsiveness to treatment.

The Influence of a Mouthpiece-Based Topography Measurement Device on Electronic Cigarette User's Plasma Nicotine Concentration, Heart Rate, and Subjective Effects Under Directed and Ad Libitum Use Conditions

INTRODUCTION

Electronic cigarettes e-cigarettes aerosolize a liquid solution often containing nicotine. e-cigarette nicotine delivery may be influenced by user puffing behaviors ("puff topography"). E-cigarette puff topography can be recorded using mouthpiece-based computerized systems. The present study sought to examine the extent to which these systems influence e-cigarette nicotine delivery and other e-cigarette associated acute effects under ad libitum use conditions.

METHODS

Plasma nicotine concentration, heart rate, and subjective effects were assessed in 29 experienced e-cigarette users using their preferred e-cigarette battery and liquid (≥12mg/mL nicotine) in two sessions differing only by the presence of a mouthpiece-based device. In both sessions, participants completed a directed e-cigarette use bout (10 puffs, 30-s interpuff interval) and a 90-min ad libitum bout. Puff topography was recorded in the session with the topography mouthpiece.

RESULTS

Plasma nicotine, heart rate, and subjective effects, aside from "Did the e-cigarette Taste Good?" were independent of topography measurement (higher mean taste ratings were observed in the no topography condition). Mean (SEM) plasma nicotine concentration following the ad libitum bout was 34.3ng/mL (4.9) in the no topography condition and 35.7ng/mL (4.3) in the topography condition. Longer puff durations, longer interpuff intervals, and larger puff volumes were observed in the ad libitum relative to the directed bout.

CONCLUSIONS

E-cigarette use significantly increased plasma nicotine concentration and heart rate while suppressing abstinence symptoms. These effects did not differ when a topography mouthpiece was present. Future studies using ad libitum e-cigarette use bouts would facilitate understanding of e-cigarette toxicant yield.

IMPLICATIONS

No prior study has examined whether mouthpiece-based topography recording devices influence e-cigarette associated nicotine delivery, heart rate, or subjective effects under ad libitum conditions or assessed ad libitum puff topography in experienced individuals using their preferred e-cigarette battery and liquid with a mouthpiece-based computerized device. E-cigarette use significantly increased plasma nicotine concentration and heart rate while suppressing abstinence symptoms. These effects did not differ when a topography mouthpiece was present. Ad libitum puff topography differed from puff topography recorded during directed puffing. These findings suggest that future studies using ad libitum use bouts would facilitate better understanding of e-cigarette toxicant yield.

Expanding clinical laboratory tobacco product evaluation methods to loose-leaf tobacco vaporizers

BACKGROUND

Novel tobacco products entering the US market include electronic cigarettes (ECIGs) and products advertised to "heat, not burn" tobacco. There is a growing literature regarding the acute effects of ECIGs. Less is known about "heat, not burn" products. This study's purpose was to expand existing clinical laboratory methods to examine, in cigarette smokers, the acute effects of a "heat, not burn" "loose-leaf tobacco vaporizer" (LLTV).

METHODS

Plasma nicotine and breath carbon monoxide (CO) concentration and tobacco abstinence symptom severity were measured before and after two 10-puff (30-s interpuff interval) product use bouts separated by 60min. LLTV effects were compared to participants' own brand (OB) cigarettes and an ECIG (3.3V; 1.5ohm; 18mg/ml nicotine).

RESULTS

Relative to OB, LLTV increased plasma nicotine concentration to a lesser degree, did not increase CO, and did not appear to reduce abstinence symptoms as effectively. Relative to ECIG, LLTV nicotine and CO delivery and abstinence symptom suppression did not differ. Participants reported that both the LLTV and ECIG were significantly less satisfying than OB.

CONCLUSIONS

Results demonstrate that LLTVs are capable of delivering nicotine and suppressing tobacco abstinence symptoms partially; acute effects of these products can be evaluated using existing clinical laboratory methods. Results can inform tobacco product regulation and may be predictive of the extent that these products have the potential to benefit or harm overall public health.

Examination of the mechanism of action of two pre-quit pharmacotherapies for smoking cessation

Background

There is substantial scope for improvement in the current arsenal of smoking cessation methods and techniques: even when front-line cessation treatments are utilized, smokers are still more likely to fail than to succeed. Studies testing the incremental benefit of using nicotine patch for 1–4 weeks prior to quitting have shown pre-quit nicotine patch use produces a robust incremental improvement over standard post-quit patch treatment. The primary objective of the current study is to test the mechanism of action of two pre-quit smoking cessation medications—varenicline and nicotine patch—in order to learn how best to optimize these pre-quit treatments.

Methods/Design

The study is a three group, randomized, open-label controlled clinical trial. Participants (n = 216 interested quitters) will be randomized to receive standard patch treatment (10 weeks of patch starting from a designated quit day), pre-quit patch treatment (two weeks of patch treatment prior to a quit day, followed by 10 weeks post-quit treatment) or varenicline (starting two weeks prior to quit day followed by 10 weeks post-quit). Participants will use study-specific modified smart-phones to monitor their smoking, withdrawal symptoms, craving, mood and social situations in near real-time over four weeks; two weeks prior to an assigned quit date and two weeks after this date. Smoking and abstinence will be assessed at regular study visits and biochemically verified.

Discussion

Understanding how nicotine patches and varenicline influence abstinence may allow for better tailoring of these treatments to individual smokers.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12614000329662 (Registered: 27 March 2014).

Smoking Trends and Disparities Among Black and Non-Hispanic Whites in California

OBJECTIVES

The current study examined disparities in smoking trends across Blacks and non-Hispanic Whites in California.

METHODS

Data from the 1996 to 2008 California Tobacco Survey were analyzed to examine trends in smoking behaviors and cessation across Blacks and non-Hispanic Whites.

RESULTS

A decrease in overall ever and current smoking was observed for both Black and non-Hispanic Whites across the 12-year time period. A striking decrease in proportions of heavy daily smokers for both Black and non-Hispanic Whites were observed. Proportions of light and intermittent smokers and moderate daily smokers displayed modest increases for Blacks, but large increases for non-Hispanic Whites. Increases in successful cessation were also observed for Blacks and, to a lesser extent, for non-Hispanic Whites.

DISCUSSION

Smoking behavior and cessation trends across Blacks and non-Hispanic Whites were revealing. The decline in heavy daily and former smokers may demonstrate the success and effectiveness of tobacco control efforts in California. However, the increase in proportions of light and intermittent smokers and moderate daily smokers for both Blacks and non-Hispanic Whites demonstrates a need for tobacco cessation efforts focused on lighter smokers.

Acute Effects of "Hyping" a Black&Mild Cigarillo

INTRODUCTION

Cigars remain a widely used tobacco product among adolescent and adult populations. The appeal of a certain type of cigar, the cigarillo, may be enhanced by users' beliefs that their harm potential can be reduced by removing the inner tobacco liner before use (a.k.a. "hyping"). The purpose of this within-subject study was to compare the acute effects of smoking an original cigarillo, a modified ("hyped") cigarillo, and an unlit cigarillo.

METHODS

Twenty smokers (19 males, 1 female; 19 non-Hispanic blacks, 1 Hispanic "other") of at least 7 Black&Mild (B&M) cigarillos/week and at most 5 cigarettes/day completed the study. All participants reported hyping their cigarillos at least occasionally. Primary outcomes, assessed over two, 30-minute smoking bouts, included plasma nicotine, expired air carbon monoxide (CO) concentration, subjective ratings (product effects, nicotine abstinence symptoms), and puff topography.

RESULTS

Mean plasma nicotine concentration increased significantly within (pre- to post-bouts), but not between, original and modified B&M conditions. Mean CO concentration was significantly lower for modified, relative to original, B&M smoking at all post-administration timepoints. Both smoked conditions significantly increased ratings of positive product effects (satisfaction, pleasant) and decreased abstinence symptom magnitude; however, ratings generally did not differ between these conditions. Overall, topography outcomes did not differ between modified and original B&M smoking.

CONCLUSIONS

Results are consistent with a previous report in that "hyping" may decrease users' CO, but not nicotine, exposure. While these data collectively suggest reduced exposure to CO acutely with engagement in "hyping," longer-term assessments are needed to determine the impact on individual and public health.

Differential Efficacy of Nicotine Replacement Among Overweight and Obese Women Smokers

INTRODUCTION

Rates of obesity are higher among more dependent smokers and 37%-65% of smokers seeking cessation treatment are overweight or obese. Overweight or obese smokers may possess metabolic and neurobiological features that contribute to difficulty achieving cessation using front-line nicotine replacement products. Attention to factors that facilitate effective cessation treatment in this vulnerable population is needed to significantly reduce mortality risk among overweight and obese smokers.

METHOD

This secondary analysis of 2 large trials of transdermal nicotine replacement in general medical practices evaluated the hypothesis that higher body mass index (BMI) would moderate the efficacy of the nicotine patch. We examined the potential for gender to further moderate the relationship between BMI and treatment efficacy.

RESULTS

In the placebo controlled trial (N = 1,621), 21-mg patch was no more effective than placebo for assisting biochemically verified point prevalence abstinence up to 1 year after quitting for women with higher BMI, but appeared to be effective for men at normal or high BMI (gender × BMI beta = -0.22, p = .004). We did not find differential long-term cessation outcomes among male or female smokers in the 15-mg patch trial (n = 705). However, we observed significantly higher rates of early lapse among women with higher BMI treated with nicotine patch across both trials.

CONCLUSION

These results suggest that increased BMI may affect the efficacy of nicotine patch on reducing risk of early lapse in women. Additional research is needed to explore mechanisms of risk for decreased efficacy of this commonly used cessation aid.

Comparison of puff topography, toxicant exposure, and subjective effects in low- and high-frequency waterpipe users: a double-blind, placebo-control study

INTRODUCTION

Clinical laboratory work among intermittent and daily waterpipe tobacco smokers has revealed significant risks for tobacco dependence and disease associated with waterpipe tobacco smoking (WTS). No studies have compared these groups directly. This study examined whether WTS frequency was associated with differential puff topography, toxicant exposure, and subjective response using a placebo-control design.

METHODS

Eighty participants reporting WTS of 2-5 episodes (LOW; n = 63) or ≥20 episodes (HIGH; n = 17) per month for ≥6 months completed 2 double-blind, counterbalanced 2-hr sessions that were preceded by ≥12hr of tobacco abstinence. Sessions differed by product smoked ad libitum for 45+ min: preferred brand/flavor of waterpipe tobacco (active) or a flavor-matched tobacco-free waterpipe product (placebo). Outcomes included puff topography, plasma nicotine, carboxyhemoglobin (COHb), and subjective response.

RESULTS

HIGH users had more puffs, shorter inter-puff-intervals, and a higher total puff volume for placebo relative to active, as well as relative to LOW users during placebo. Plasma nicotine concentrations increased when smoking active (but not placebo) with no significant differences between groups at 25min post-product administration. COHb increased significantly during all conditions; the largest increase was for HIGH users when smoking placebo. There was some evidence of higher baseline scores for nicotine/tobacco nicotine abstinence symptomology.

CONCLUSIONS

Higher frequency waterpipe users may be more sensitive to the effects of waterpipe smoke nicotine content. Among HIGH users, higher baseline nicotine/tobacco abstinence symptoms may indicate greater nicotine dependence. These data support continued surveillance of WTS and development of dependence measures specific to this product.

Preliminary results of an examination of electronic cigarette user puff topography: the effect of a mouthpiece-based topography measurement device on plasma nicotine and subjective effects

INTRODUCTION

Electronic cigarettes (ECIGs) heat a nicotine-containing solution; the resulting aerosol is inhaled by the user. Nicotine delivery may be affected by users' puffing behavior (puff topography), and little is known about the puff topography of ECIG users. Puff topography can be measured using mouthpiece-based computerized systems. However, the extent to which a mouthpiece influences nicotine delivery and subjective effects in ECIG users is unknown.

METHODS

Plasma nicotine concentration, heart rate, and subjective effects were measured in 13 experienced ECIG users who used their preferred ECIG and liquid (≥ 12 mg/ml nicotine) during 2 sessions (with or without a mouthpiece). In both sessions, participants completed an ECIG use session in which they were instructed to take 10 puffs with 30-second inter-puff intervals. Puff topography was recorded in the mouthpiece condition.

RESULTS

Almost all measures of the effects of ECIG use were independent of topography measurement. Collapsed across session, mean plasma nicotine concentration increased by 16.8 ng/ml, and mean heart rate increased by 8.5 bpm (ps < .05). Withdrawal symptoms decreased significantly after ECIG use. Participants reported that the mouthpiece affected awareness and made ECIG use more difficult. Relative to previously reported data for tobacco cigarette smokers using similar topography measurement equipment, ECIG-using participants took larger and longer puffs with lower flow rates.

CONCLUSIONS

In experienced ECIG users, measuring ECIG topography did not influence ECIG-associated nicotine delivery or most measures of withdrawal suppression. Topography measurement systems will need to account for the low flow rates observed for ECIG users.

An exploratory examination of the mechanisms through which pre-quit patch use aids smoking cessation

RATIONALE AND OBJECTIVES

Patches are traditionally started on the day a quit attempt begins. Recently, a number of studies have established that the patch's effectiveness is improved by starting the treatment before quitting [pre-quit patch (PQP) use]. In an exploratory study, we investigate a proposed mechanism through which PQP use might promote abstinence: that PQP reduces satisfaction with smoking (either directly or via craving), which in turn leads to reduction and that smoking reduction promotes abstinence.

METHODS

Fifty-seven interested quitters used handheld computers to monitor their smoking satisfaction, withdrawal and smoking in real time for 17 days, leading up to a quit attempt. All participants received 21 mg/24 h patches for 2 weeks before and for up to 10 weeks after quitting. Carbon dioxide (CO)-verified 28-day abstinence was assessed.

RESULTS

During PQP treatment, participants reported significant reductions in both the satisfaction gained from smoking (p < 0.001) and their daily cigarette consumption (p < 0.001). Craving did not decrease; however, there was an interaction between time and nicotine dependence; craving decreased only among low dependent participants. Multilevel structural equation modelling revealed a direct effect of satisfaction on smoking rate. Craving did not mediate this relationship. Smoking reduction during the PQP treatment phase was not significantly associated with abstinence.

CONCLUSIONS

The real-time data collection protocol utilised allowed for a fine-grained examination of smoking during PQP treatment. The results suggest that the reduction in daily cigarette smoking typically observed during PQP treatment is due to reductions in satisfaction with smoking. Unlike previous studies, however, smoking reduction was not significantly related to later abstinence, even though the odds ratio was comparably. Potential clinical implications of these findings are discussed.

Urinary biomarkers of smokers' exposure to tobacco smoke constituents in tobacco products assessment: a fit for purpose approach

There are established guidelines for bioanalytical assay validation and qualification of biomarkers. In this review, they were applied to a panel of urinary biomarkers of tobacco smoke exposure as part of a "fit for purpose" approach to the assessment of smoke constituents exposure in groups of tobacco product smokers. Clinical studies have allowed the identification of a group of tobacco exposure biomarkers demonstrating a good doseresponse relationship whilst others such as dihydroxybutyl mercapturic acid and 2-carboxy-1-methylethylmercapturic acid - did not reproducibly discriminate smokers and non-smokers. Furthermore, there are currently no agreed common reference standards to measure absolute concentrations and few inter-laboratory trials have been performed to establish consensus values for interim standards. Thus, we also discuss in this review additional requirements for the generation of robust data on urinary biomarkers, including toxicant metabolism and disposition, method validation and qualification for use in tobacco products comparison studies.

Developing a Rational Approach to Tobacco Use Treatment in Pulmonary Practice: A Review of the Biological Basis of Nicotine Addiction

The toll of tobacco use on a pulmonary practice is severe. Physicians, patients, and their families experience frustration, hopelessness and even anger when confronted with a seemingly irrational decision to keep smoking despite morbid lung disease. This paper examines the biological basis of this behavior and seeks to integrate this insight into a rational approach to the problem in practice. Smoking is reexamined within the framework of an irrational compulsion to seek nicotine, despite a rational desire to stop. Control over the compulsion to smoke is established as an important clinical outcome, and the rationale for treating tobacco dependence as a chronic illness is examined. Finally, practical insights into managing ambivalence, including an aggressive pharmacotheapeutic approach based on the neurobiology, are presented.

The use of nicotine replacement therapy for smoking reduction and temporary abstinence: an interview study

INTRODUCTION

Nicotine replacement therapy (NRT) is commonly used to aid smoking reduction (SR) or in situations of enforced temporary abstinence (TA). National Surveys have suggested that in the general population of smokers, the use of NRT in these ways has little effect on cigarette consumption and that use of the nicotine patch is common. This study aimed to gain a better understanding of what might underlie this.

METHODS

Semistructured telephone interviews were conducted with 36 smokers who reported that they were using NRT for SR and/or TA. Open-ended questions explored smokers' knowledge, beliefs, and experience of using NRT for SR and/or TA. Interviews were analyzed using a variant of framework analysis.

RESULTS

Smokers reported using a variety of methods to reduce their cigarette consumption, including increasing the interval between cigarettes and attempting nondaily or social smoking. Smokers also modified how they smoked their cigarettes by trying to inhale less, not inhaling at all, or only smoking part of the cigarette. Nicotine patches appeared to be popular because they were discreet, easy to use, provided a prolonged effect, and had an established history. Smokers had little knowledge of the regulatory restrictions on the use of NRT.

CONCLUSIONS

Smokers used a wide variety of means of reducing smoke exposure without stopping completely, including ones that did not involve reducing consumption. Nicotine patches were considered convenient to help with this, and there appeared to be little awareness of regulatory restrictions on their use.

Shorter interpuff interval is associated with higher nicotine intake in smokers with schizophrenia

BACKGROUND

People with schizophrenia are frequent and heavy smokers.

METHODS

The objective of this study was to measure serum nicotine levels and ad libitum smoking behavior for 24+2h using the CReSS micro topography device in 75 smokers with schizophrenia (SCZ) and compare these to 86 control smokers (CON) without mental illness. Mean values of repeatedly measured topography variables were compared using three-level nested linear models to adjust for between subject differences and the double nested data.

RESULTS

Smokers with SCZ smoked more cigarettes in the 24h period and took an average of 2.8 more puffs per cigarette than CON (p<0.001). The time between puffs, or interpuff interval (IPI), was shorter in SCZ by an average of 6.5s (p<0.001). The peak flow rate was higher in SCZ by an average of 4.9 ml/s (p<0.05). Smokers with SCZ spent an average of 1.0 min less time smoking a single cigarette vs. CON (p<0.001). Smokers with SCZ also had shorter IPI and more puffs per cigarette in an analysis of first cigarette of the day. For all subjects, a decrease in IPI by 1s was associated with an increase in serum nicotine of 0.19 ng/ml and in cotinine of 5.01 ng/ml (both p<0.05). After controlling for diagnosis group, higher craving scores on QSU Factor 2 (urgent desire to smoke) were associated with shorter IPI.

DISCUSSION

Smokers with schizophrenia demonstrate more intense cigarette puffing that is associated with greater nicotine intake. This pattern may provide insight into other heavily dependent smokers.

Acute effects of waterpipe tobacco smoking: a double-blind, placebo-control study

BACKGROUND

Waterpipe tobacco smoking usually involves heating flavored tobacco with charcoal and inhaling the resulting smoke after it has passed through water. Waterpipe tobacco smoking increases heart rate and produces subjective effects similar to those reported by cigarette smokers. These responses are thought to be nicotine-mediated, though no placebo-control studies exist. Accordingly, this double-blind, placebo-control study compared the acute physiological and subjective effects of waterpipe tobacco smoking to those produced when participants used a waterpipe to smoke a flavor-matched, tobacco-free preparation.

METHODS

Occasional waterpipe tobacco smokers (n = 37; 2-5 monthly smoking episodes for ≥ 6 months) completed two double-blind, counterbalanced sessions that differed by product: preferred brand/flavor of waterpipe tobacco or flavor-matched, tobacco-free preparation. For each 45-min, ad lib smoking episode blood and expired air CO were sampled, cardiovascular and respiratory response were measured, and subjective response was assessed.

RESULTS

Waterpipe tobacco smoking significantly increased mean (± SEM) plasma nicotine concentration (3.6 ± 0.7 ng/ml) and heart rate (8.6 ± 1.4 bpm) while placebo did not (0.1 ± 0.0 ng/ml; 1.3 ± 0.9b pm). For carboxyhemoglobin (COHb) and expired air CO, significant increases were observed for tobacco (3.8 ± 0.4%; 27.9 ± 2.6 ppm) and for placebo (3.9 ± 0.4%; 27.7 ± 3.3 ppm) with no differences across condition. Independent of condition, symptoms of nicotine/tobacco abstinence (e.g., "urges to smoke", "anxious") were reduced and direct effects (e.g., "dizzy", "satisfy") increased.

DISCUSSION

These results from the first placebo-control study of waterpipe tobacco smoking demonstrate that waterpipe-induced heart rate increases are almost certainly mediated by nicotine though the subjective effects observed in these occasional smokers were not.

Vaccination against nicotine alters the distribution of nicotine delivered via cigarette smoke inhalation to rats

Preclinical models of nicotine vaccine pharmacology have relied on i.v. or s.c. administration of nicotine. Models using cigarette smoke inhalation might more accurately simulate nicotine exposure in smokers. Nicotine vaccine effects were examined in rats using two cigarette smoke exposure models: a 10 min nose-only exposure (NSE) producing serum nicotine levels equivalent to the nicotine boost from 1 cigarette in a smoker, and a 2h whole-body exposure (WBE) producing serum nicotine levels similar to those associated with regular mid-day smoking. Vaccination prior to 10min smoke NSE reduced nicotine distribution to brain by 90%, comparable to its effect on nicotine administered i.v. Vaccination prior to 2 h smoke WBE reduced nicotine distribution to brain by 35%. The nicotine concentration in broncheoalveolar lavage (BAL) fluid obtained after 2 h WBE was increased by 230% in vaccinated rats but was also increased in rats passively immunized with a nicotine-specific monoclonal antibody, and so was likely due to transfer of antibody from serum rather than local production at the pulmonary mucosa. Nicotine-specific IgA was not detectable in BAL fluid, but titers in serum were appreciable at 21-25% of the IgG titer and could contribute to vaccine efficacy. Both vaccination and passive immunization are effective in reducing nicotine distribution to brain in rats when nicotine is delivered via inhaled cigarette smoke. These data validate results previously obtained in rodents for nicotine vaccines using i.v. or s.c. nicotine dosing and provide a quantitative method for studying aspects of nicotine exposure which are unique to cigarette smoke inhalation.

Acute effects of cigarillo smoking

INTRODUCTION

Cigarillo smoking likely exposes users to many of the same toxicants (e.g., nicotine, carbon monoxide [CO]) as cigarette smoking. Yet, few controlled clinical laboratory studies evaluating of the effects of cigarillos exist. This study evaluated the cardiovascular response, toxicant exposure, subjective effects, and puffing topography of a popular cigarillo brand, Black & Mild (B&M).

METHODS

Sixteen B&M smokers (M ± SD = 1.9 ± 2.5 cigarillos/day for 3.4 ± 3.5 years) participated in 2 counterbalanced conditions: lit (ACTIVE) or unlit (SHAM) B&M in which they completed two 10-puff smoking bouts (30-s interpuff intervals).

RESULTS

Plasma nicotine concentrations for ACTIVE increased significantly from pre-smoking (M ± SEM = 2.0 ± 0.0 ng/ml) to 5 min after Bouts 1 (5.3 ± 0.8 ng/ml) and 2 (4.9 ± 0.9 ng/ml) but did not increase above 2.0 ± 0.0 ng/ml at any timepoint for SHAM. Heart rate increased significantly from pre- to post-smoking for ACTIVE but not for SHAM. Average expired-air CO levels, collapsed across time, were 14.3 ± 0.8 ppm for ACTIVE and 4.5 ± 0.2 ppm for SHAM. Neither condition reduced symptoms of nicotine/tobacco abstinence reliably, although ratings for some measures were significantly lower for ACTIVE than for SHAM. ACTIVE, but not SHAM, produced a variety of positive effects related to product sensory characteristics (e.g., "satisfying," "pleasant"). Smoking topography did not differ across the two conditions.

CONCLUSIONS

Ten puffs from a B&M cigarillo deliver active doses of nicotine and considerable amounts of CO but do not suppress abstinence-induced withdrawal symptoms reliably. The nicotine delivery profile suggests that cigarillo smoking may promote nicotine/tobacco dependence and the CO exposure likely poses significant health risks.

Do smokers of menthol cigarettes find it harder to quit smoking?

INTRODUCTION

Menthol cigarette smokers may find it harder to quit smoking than smokers of nonmenthol cigarettes.

METHODS

We conducted a systematic review of published studies examining the association between menthol cigarette smoking and cessation. Electronic databases and reference lists were searched to identify studies published through May 2010, and results were tabulated.

RESULTS

Ten studies were located that reported cessation outcomes for menthol and nonmenthol smokers. Half of the studies found evidence that menthol smoking is associated with lower odds of cessation, while the other half found no such effects. The pattern of results in these studies suggest that the association between smoking menthol cigarettes and difficulty quitting is stronger in (a) racial/ethnic minority populations, (b) younger smokers, and (c) studies carried out after 1999. This pattern is consistent with an effect that relies on menthol to facilitate increased nicotine intake from fewer cigarettes where economic pressure restricts the number of cigarettes smokers can afford to purchase.

CONCLUSIONS

There is growing evidence that certain subgroups of smokers find it harder to quit menthol versus nonmenthol cigarettes. There is a need for additional research, and particularly for studies including adequately powered and diverse samples of menthol and nonmenthol smokers, with reliable measurement of cigarette brands, socioeconomic status, and biomarkers of nicotine intake.

Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects

INTRODUCTION

Waterpipe tobacco smoking is increasing worldwide and is believed by many users to be less harmful and addictive than cigarette smoking. In fact, waterpipe tobacco and cigarette smoke contain many of the same chemicals, and users are exposed to the dependence-producing drug nicotine as well as other smoke toxicants. The subjective effect profile of these 2 tobacco use methods has not been compared directly, though this information is relevant to understanding the risk of dependence development.

METHODS

Fifty-four participants who reported waterpipe and cigarette smoking completed 2, 45-min, counter-balanced sessions in which they completed a waterpipe use episode (mean smoking time = 43.3 min) or a cigarette (mean = 6.1 min). Outcome measures included plasma nicotine, carboxyhemoglobin (COHb), and subjective effects, including those relevant to predicting dependence potential.

RESULTS

Mean (±SEM) peak plasma nicotine concentration did not differ by session (waterpipe = 9.8 ± 1.0 ng/ml; cigarette = 9.4 ± 1.0 ng/ml). Mean peak COHb concentration differed significantly (waterpipe = 4.5% ± 0.3%; cigarette = 1.2% ± 0.1%). Subjective effect changes for waterpipe and cigarette were comparable in magnitude but often longer lived for waterpipe.

CONCLUSIONS

Relative to a cigarette, waterpipe tobacco smoking was associated with similar peak nicotine exposure, 3.75-fold greater COHb, and 56-fold greater inhaled smoke volume. Waterpipe and cigarette influenced many of the same subjective effect measures. These findings are consistent with the conclusion that waterpipe tobacco smoking presents substantial risk of dependence, disease, and death, and they can be incorporated into prevention interventions that might help deter more adolescents and young adults from experimenting with an almost certainly lethal method of tobacco use.

Evaluating the acute effects of oral, non-combustible potential reduced exposure products marketed to smokers

BACKGROUND

Non-combustible potential reduced exposure products (PREPs; eg, Star Scientific's Ariva; a variety of other smokeless tobacco products) are marketed to reduce the harm associated with smoking. This marketing occurs despite an absence of objective data concerning the toxicant exposure and effects of these PREPs. Methods used to examine combustible PREPs were adapted to assess the acute effects of non-combustible PREPs for smokers.

METHODS

28 overnight abstinent cigarette smokers (17 men, 14 non-white) each completed seven, Latin-squared ordered, approximately 2.5 h laboratory sessions that differed by product administered: Ariva, Marlboro Snus (Philip Morris, USA), Camel Snus (RJ Reynolds, Winston-Salem, North Carolina, USA), Commit nicotine lozenge (GlaxoSmithKline; 2 mg), own brand cigarettes, Quest cigarettes (Vector Tobacco; delivers very low levels of nicotine) and sham smoking (ie, puffing on an unlit cigarette). In each session, the product was administered twice (separated by 60 min), and plasma nicotine levels, expired air CO and subjective effects were assessed regularly.

RESULTS

Non-combustible products delivered less nicotine than own brand cigarettes, did not expose smokers to CO and failed to suppress tobacco abstinence symptoms as effectively as combustible products.

CONCLUSIONS

While decreased toxicant exposure is a potential indicator of harm reduction potential, a failure to suppress abstinence symptoms suggests that currently marketed non-combustible PREPs may not be a viable harm reduction strategy for US smokers. This study demonstrates how clinical laboratory methods can be used to evaluate the short-term effects of non-combustible PREPs for smokers.

Longitudinal associations between people's cessation-related experiences and their satisfaction with cessation

We sought to determine whether different social, psychological, emotional, and physiological experiences associated with quitting smoking related to people's satisfaction with cessation systematically, and whether the strength of the relations changes at different points during the cessation process and for different people (e.g., optimists). Using data from smokers enrolled in a cessation program, we used mixed models to assess the average longitudinal relation between people's experiences and satisfaction measured at seven time points and whether the relations were moderated by key variables. Eight of nine experiences were related to people's satisfaction (ps < 0.05) and the models accounted for 39-44% of the within-person variance in satisfaction. Current smoking behavior was more strongly related to people's satisfaction during their early efforts to quit, whereas some experiences (e.g., feedback from others) had a stronger relation with satisfaction during people's later efforts to quit or maintain abstinence (ps < 0.05). Individual differences in optimism and prior cessation experience moderated some of the relations (ps < 0.05). The findings mark the first evidence of factors that might influence how people determine their satisfaction with smoking cessation. The implications for tailoring interventions and potentially increasing the likelihood that people maintain abstinence are discussed.

Measures for assessing subjective effects of potential reduced-exposure products

Potential reduced-exposure products (PREP) may reduce toxicant exposure and thereby may possibly reduce health risks associated with conventional tobacco use. However, lessened health risk to the individual or harm to the population through the use of PREPs is unknown. Research is being conducted to evaluate the possible health effects associated with PREP use. As part of this evaluation, it is critical to provide sound measures of subjective responses to PREPs to determine the use and the abuse potential of a product, that is, the likelihood that the product will lead to addiction. The goal of this paper is to conduct a systematic review of scales that have been used to measure the subjective responses to PREPs and examine their characteristics. In this article, scales are identified and the items on the scales are described. Scales are also examined to determine whether they are sensitive in testing PREPs. Furthermore, scales to assess PREPs are recommended to investigators. Where no scales exist, items that may be critical for the development and validation of new scales are identified.

Behavioral interventions in tobacco dependence

Patients who smoke represent a frustrating social paradox. The harmful effects of tobacco use have been well publicized in the past 50 years, yet more than one in five adults in the United States continue to smoke. A better understanding of the nature of nicotine addiction, of behavioral learning, and of common misconceptions regarding tobacco use treatment, can create new opportunities to impact smoking by offering clinicians novel methods of influence that have otherwise not be available within the traditional cessation approach. Understanding and dealing with the paradox can provide more productive and meaningful ways of improving not only health, but potentially also improving well-being.

Precessation treatment with nicotine patch significantly increases abstinence rates relative to conventional treatment

INTRODUCTION

Previous studies have reported that smoking abstinence rates are increased when nicotine skin patch treatment is initiated prior to the target quit smoking date, as compared with conventional treatment beginning on the quit date. We hypothesized that smoking in the presence of continuous levels of nicotine would attenuate the reinforcing effects of cigarette smoking and lead to a decline in dependence on inhaled nicotine, thus facilitating cessation.

METHODS

This study involved four groups of smokers (n = 100 per group) who received either nicotine patch (21 mg/24 hr) or placebo patch treatment for 2 weeks before the quit smoking date, and during this period, smoked their usual brands of cigarettes or switched to low-tar and nicotine cigarettes: a 2 (nicotine patch) x 2 (cigarette type) factorial design. From the quit date on, all groups received standard nicotine patch treatment, consisting of 6 weeks of 21 mg/24 hr, 2 weeks of 14 mg/24 hr, and 2 weeks of 7 mg/24 hr. Abstinence was defined as self-report of no smoking from the quit date on, confirmed by expired-air carbon monoxide.

RESULTS

Continuous abstinence rates were approximately doubled by precessation nicotine patch treatment. The treatment mainly benefited smokers with lower levels of dependence, based on Fagerström Test for Nicotine Dependence score. All treatments were well tolerated.

DISCUSSION

In view of these findings and similar results from previous studies, current labeling of the nicotine patch, which recommends using nicotine replacement therapy only after the quit date, should be reexamined.

Nicotine patch therapy prior to quitting smoking: a meta-analysis

AIM

To evaluate the incremental efficacy of starting nicotine patch treatment prior to quitting compared to the current regimen of starting patch treatment on the target quit day.

DESIGN AND MEASUREMENTS

Meta-analysis of four eligible studies using pre-cessation patch treatment, located by database search and contacts with cessation researchers. The studies all compared starting treatment with nicotine patch prior to the target quit date to starting active treatment at the quit date, some in the context of concurrent mecamylamine treatment. The primary end-point for the analysis was continuous abstinence for at least 28 days assessed at 6 weeks following quit day; 6-month outcomes were also examined.

FINDINGS

Compared to starting active patch treatment on quit day, pre-cessation treatment with nicotine patches was found to double the odds of quitting. This was true both at 6 weeks [pooled odds ratio (OR) = 1.96, 95% confidence interval (CI): 1.31-2.93] and 6 months (pooled OR = 2.17, 95% CI: 1.46-3.22) treatment outcomes. Mecamylamine co-treatment did not modify these effects.

CONCLUSIONS

Across the four studies analyzed, pre-cessation patch treatment was found to produce a robust increase in quit rates compared to current regimens starting patch at quit day. Pre-cessation patch use represents a promising innovation in smoking cessation therapy with potential beneficial implications for improved public health by further increasing quitting success.

Is low-nicotine Marlboro snus really snus?

Swedish snus is a medium/high nicotine delivery, low-nitrosamine moist smokeless tobacco product that has been estimated to be at least 90% less harmful than smoked tobacco. More men use snus than smoke cigarettes in Sweden, and a quarter of male former smokers quit by switching to snus. Leading multinational cigarette manufacturers have begun test-marketing snus-like products in the United States and other countries. The version of Philip Morris' Marlboro snus currently being marketed in the United States differs from Swedish snus in many ways; it has lower moisture content and pH, but most puzzling is its very low nicotine delivery. Philip Morris, the market-leader in United States cigarette sales, may have designed the product so that it does not satisfy nicotine cravings and fails to enable smokers to switch. In this paper we compare and contrast Swedish snus and Marlboro snus, and speculate as to why Philip Morris may have intentionally designed a product that delivers very low levels of nicotine. We recommend that Philip Morris cease using the term "snus" to refer to dry tobacco products with low nicotine delivery, so that the term be reserved for moist, low-toxin, medium/high nicotine delivery smokeless tobacco products that are qualitatively similar to the leading brands in Sweden.

Pre-quitting nicotine replacement therapy: findings from a pilot study

Background

Using nicotine replacement therapy (NRT) while still smoking in the lead up to quitting could enhance success at quitting, one of the most cost-effective means of improving health, but little is known about its acceptability and tolerability.

Aim

To test the acceptability and tolerability of using NRT while smoking for two weeks before quitting, to inform a randomised controlled trial of pre-quitting NRT versus usual NRT-based quitting practice.

Methods

Prospective pragmatic uncontrolled clinic-based pilot study in which 14 adult smokers recruited from a smoking cessation clinic were prescribed nicotine patches or gum with follow up for two weeks. Data were collected on participants' concerns about smoking while using NRT, importance of quitting, urges to smoke, smoking behaviour, previous NRT use and the length of the pre-quitting period. Urine tests were collected weekly for cotinine, and participants recorded smoking activity and noted experiences and changes in their health in diaries.

Results

Only 21% of 14 participants expressed concerns about using NRT while smoking. All of the nine followed up used it as recommended, 56% of these reporting no unpleasant symptoms. Median urine cotinine levels declined over the two weeks. Urges to smoke averaged 1.8 on a 4-point scale. All participants decreased the number of cigarettes per day. Diary records showed wide variation in smoking and NRT use, with an increased sense of control and determination to quit.

Conclusion

Smokers using pre-quitting NRT over two weeks appeared to titrate nicotine levels and symptoms of toxicity were uncommon and of low intensity.

Immediate hedonic response to smoking lapses: relationship to smoking relapse, and effects of nicotine replacement therapy

OBJECTIVE AND RATIONALE

Smoking lapses represent an important juncture between smoking cessation and relapse. Nicotine replacement therapy (NRT) has been shown to decrease the risk of progression from lapse to relapse. We hypothesized that this effect might be mediated via decreases in reinforcement from smoking lapses.

METHOD

We assessed 169 subjects who lapsed during treatment in a double-blind placebo-controlled study of high-dose (35 mg) nicotine patch. Following their first lapse, using an electronic diary, subjects recorded the amount they smoked, and rated the pleasantness and satisfaction ("hedonic rating") and the aversiveness of smoking. Subjects were then followed and assessed for further lapses and relapses.

RESULTS

Subjects who smoked more during the first lapse had greater risk of progression [second lapse: hazard ratio (HR)=1.16, confidence interval (CI)=1.01-1.32; relapse: HR=1.22, CI=0.97-1.54]. Subjects with higher hedonic ratings of the first lapse also had a greater risk of progression to the second lapse (HR=1.08, CI=1.02-1.14) and to relapse (HR=1.26, CI=1.11-1.41). Aversive ratings had no bearing on progression. As expected, active treatment reduced the risk of both a second lapse (HR=0.54, CI=0.39-0.78) and a relapse (HR=0.22, CI=0.11-0.45). Importantly, however, NRT had no effect on hedonic ratings, amount smoked during the first lapse, or aversive ratings.

CONCLUSIONS

Hedonic response to an initial lapse predicted progression to relapse, but this did not mediate the effect of NRT on progression.

Nicotine replacement therapy and ischaemic stroke

A52-year-old right-handed businessman developed sudden onset of non-fluent dysphasia, weakness and sensory disturbance on the right side of his body 3 weeks after starting Nicorette patches (21 mg). He continued to smoke 3–5 cigars a day while on these patches. The patient had a history of depression and excessive alcohol intake.

Examination confirmed an expressive dysphasia with verbal fluency limited to five words beginning with ‘C’ or ‘S’ but with no problems in comprehension, naming or praxis. Rapid alternating movements were impaired on the right and reflexes were brisker on the right side, although both planters were flexor. Cardiovascular and general examination was unremarkable.

Magnetic resonance imaging (MRI) brain scan confirmed a left anterior cerebral artery territory infarct. The following blood tests were normal or unhelpful: erythrocyte sedimentation rate (ESR), C-reactive protein, protein culture and sensitivity, antithrombin, antiphospholipid coagulant, treponemal serology, thyroid screen and autoantibody screen. The patient was found to have mildly raised triglyceride (2.42 mmol/l) and low density lipoprotein (LDL) cholesterol (4.61 mmo/l). Electrocardiogram (ECG), echocardiography and carotid Dopplers were all normal.

Two previous cases of stroke following nicotine patches have been reported by Jackson (1993) and Pierce (1994). In addition, the Medicines and Healthcare products Regulatory Agency (MHRA) have received 12 further cases of cerebrovascular disorders following nicotine replacement (Table 1).

Individual self-administration of nicotine by rats

Self-administration (SA) of nicotine (N) was studied in 20 male and 19 female N:NIH rats using the two-bottle method. The experimental protocol consisted of seven consecutive periods each lasting 6 days: Period (P)1, choice of water (W) and 0.003% N; P2, choice of W and 0.006% N; P3, choice of W and 0.012% N; P4, W only; P5, choice of W and 0.006% N; P6, 0.006% N only; and P7, choice of W and 0.006% N. Group means showed that males and female rats consumed similar amounts of N during Ps 1-3. After an N-free period (P4), a small decline was observed in the subsequent voluntary intake of N (P5). Forced N (P6) exposure did not affect a subsequent N intake (P7) in males but increased it slightly in females. A survey of individual animals, however, showed that the voluntary N consumption varied greatly among animals, but was quite consistent for a particular rat. Values ranged from 0.43 to 7.59 for males and from 0.35 to 4.69 mg/kg/day for females for Ps 1-3. The N-free (P4) and the forced-N (P6) periods each affected a subsequent voluntary N intake (P5, P7) of the rats very differently, but again consistently, in that some rats decreased, some increased and some did not change their N choice. The results indicate that group means can be misleading in their conclusions and strongly support the assumption that the response of an individual animal to N, and not N per se, is the determining force of its SA.

Effect of pre-treatment with nicotine patch on withdrawal symptoms and abstinence rates in smokers subsequently quitting with the nicotine patch: a randomized controlled trial

AIMS

To determine whether 2-week pre-treatment with transdermal nicotine influences withdrawal symptoms or success rate of subsequent smoking cessation using nicotine patches.

DESIGN

Randomized controlled trial.

SETTING

Smoking cessation clinic.

PARTICIPANTS

Healthy smokers (n = 200, 45% female) were allocated randomly to either active nicotine-patch (AP, 15 mg daily, n = 100) or placebo-patch (PP, n = 100) pre-treatment. Baseline characteristics were well balanced except for daily cigarette consumption: mean (+/- SD) 23.1 (8) and 26.4 (11) for AP and PP groups, respectively (P = 0.021).

INTERVENTION

At the screening visit (-2 weeks) subjects were counselled and started pre-treatment with daily patches (AP or PP). From the quit date (week 0) onwards all subjects received active nicotine patches for 12 weeks (15 mg daily for 8 weeks, 10 and 5 mg daily for 2 weeks each) and counselling.

MEASUREMENTS

Follow-up visits included measurement of exhaled carbon monoxide at the quit date, 2, 6, 10 and 26 weeks. Subjects documented daily cigarette consumption and severity of withdrawal symptoms (Wisconsin scale) from -2 weeks to week 2. Outcome measures were withdrawal symptoms composite score and abstinence rates.

FINDINGS

There was no significant difference in withdrawal symptoms, but more subjects in the AP group were smoke-free during the 6-month study period. Overall sustained abstinence was documented in 17% of subjects at 6 months; 22% and 12% for AP and PP, respectively (P = 0.03). Retrospective subgroup analysis showed for subjects smoking >16 cigarettes/day sustained cessation rates were 22% and 9% for AP and PP, respectively (P = 0.01). No difference in adverse event rates was observed.

CONCLUSIONS

Nicotine patch pre-treatment before cessation did not reduce early withdrawal symptoms but increased sustained abstinence rates at 6 months. The nicotine pre-treatment was equally effective in light and heavy smokers.

Effects of continuous nicotine infusion on nicotine self-administration in rats: relationship between continuously infused and self-administered nicotine doses and serum concentrations

RATIONALE

The efficacy of nicotine replacement therapy (NRT) for smoking cessation is limited. One reason for this limited efficacy may be that typical serum nicotine concentrations provided by NRT do not match the peak arterial nicotine concentrations achieved from smoking.

OBJECTIVE

The purpose of the present study was to determine whether continuous nicotine infusion at a rate producing serum nicotine concentrations that match the estimated peak arterial nicotine concentrations associated with nicotine self-administration (NSA) in rats produces greater suppression of NSA than lower infusion rates.

METHODS

The effects of continuous nicotine infusion were studied by intravenously administering nicotine at various rates (1.0, 3.0, and 8.0 mg/kg per day) to rats concurrently self-administering nicotine (0.03 mg/kg per infusion) during 23-h sessions or cocaine (0.17 mg/kg per infusion) during 2-h sessions.

RESULTS

Continuous nicotine infusion suppressed NSA in a rate-related fashion. NSA was suppressed by 17, 50, and 73% at infusion rates of 1.0, 3.0 and 8.0 mg/kg per day, respectively. The 8.0-mg/kg per day infusion rate, which provided venous serum nicotine concentrations equaling the peak arterial concentrations associated with NSA, suppressed NSA to a greater extent than lower infusion rates. The 8.0-mg/kg per day nicotine infusion rate had no effect on cocaine-maintained responding, demonstrating that its effects were specific for suppression of NSA. This infusion rate provided a mean percentage replacement of nicotine from NSA of more than 700%. Reacquisition of NSA after suppression by the two highest infusion rates was delayed compared with reacquisition after saline extinction.

CONCLUSIONS

Continuous nicotine infusion produced an infusion rate-related suppression of NSA that was greatest when the infusion provided nicotine doses and venous serum concentrations substantially higher than those typically associated with NRT in humans.

Cigarette smoking and attention to signals of reward and threat in the Stroop paradigm

AIMS

To test the prediction arising from the incentive-sensitization model of addiction that when tested immediately after smoking, smokers will show heightened attention to words with appetitive and aversive motivational significance compared with their performance during acute abstinence.

DESIGN

Twenty-one smokers were each tested twice, once just after smoking and once after overnight abstinence, on three versions of the modified Stroop task which required colour naming of words with either neutral, appetitive or aversive connotations. Ten non-smokers were tested once.

SETTING

All participants were tested in a quiet experimental cubicle within the psychology department.

PARTICIPANTS

Smokers comprised nine men and 12 women who had smoked at least 10 cigarettes per day for the last 6 months; non-smokers comprised five men and five women who had never smoked. All were aged between 18 and 35 years. Three smokers were excluded from the analyses because their breath CO levels suggested they had not complied with the instructions to abstain on one occasion.

MEASUREMENTS

A card-based, blocked, format was used for the modified Stroop task. Time to colour-name the words of the three motivational types, the order of which was counterbalanced across participants, was recorded.

FINDINGS

Smoking was associated with greater interference from both threat and appetitive words than from neutral words; during abstinence there was no differential effect of word type. Non-smokers performed more similarly to recent smokers.

CONCLUSIONS

This pattern suggests suppression of normal motivational responding during abstinence.

Continuous nicotine infusion reduces nicotine self-administration in rats with 23-h/day access to nicotine

The effects of continuous nicotine infusion on nicotine self-administration (NSA) were studied in rats as a model of nicotine replacement therapy (NRT) in humans. A NSA model in which rats had 23-h/day access to nicotine was used to approximate nicotine access conditions in cigarette smokers. In order to estimate serum nicotine concentrations associated with NSA, arterial and venous serum nicotine concentrations were measured during a simulation of NSA. Nicotine was noncontingently administered as 30 doses/12 h of 0.03 mg/kg/i.n.f. or 60 doses/12 h of 0.01 mg/kg/i.n.f. daily. Venous serum nicotine concentrations were measured after the first nicotine dose of the day, and arterial and venous concentrations were measured after doses in the middle of the day. The range of mean concentrations measured was similar to those reported in cigarette smokers (venous concentrations 6-59 ng/ml, arterial concentrations 42-96 ng/ml). The effects of continuous nicotine infusion on NSA were studied by noncontingently administering nicotine at various rates via osmotic pump to animals self-administering nicotine (0.01 or 0.03 mg/kg/i.n.f.) during 23-h/day sessions. Continuous nicotine infusion at all infusion rates substantially suppressed NSA, but suppression was rate-related only for the 0.01-mg/kg/inf NSA unit dose. Nicotine infusion rates producing venous serum nicotine concentrations equaling or exceeding the peak venous levels associated with simulated NSA were more effective than lower infusion rates only at the lower NSA unit dose. The highest nicotine infusion rate had no sustained effect on food-maintained responding, demonstrating its specificity for suppression of NSA. These data provide a model for studying NRT in the rat.

Nicotinic--serotonergic interactions in brain and behaviour

This review focuses on nicotinic--serotonergic interactions in the central nervous system (CNS). Nicotine increases 5-hydroxytryptamine (5-HT) release in the cortex, striatum, hippocampus, dorsal raphé nucleus (DRN), hypothalamus, and spinal cord. As yet, there is little firm evidence for nicotinic receptors on serotonergic terminals and thus nicotine's effects on 5-HT may not necessarily be directly mediated, but there is strong evidence that the 5-HT tone plays a permissive role in nicotine's effects. The effects in the cortex, hippocampus, and DRN involve stimulation of 5-HT(1A) receptors, and in the striatum, 5-HT(3) receptors. The 5-HT(1A) receptors in the DRN play a role in mediating the anxiolytic effects of nicotine and the 5-HT(1A) receptors in the dorsal hippocampus and lateral septum mediate its anxiogenic effects. The increased startle and anxiety during nicotine withdrawal is mediated by 5-HT(1A) and 5-HT(3) receptors. The locomotor stimulant effect of acute nicotine is mediated by 5-HT(1A) receptors and 5-HT(2) receptors may play a role in the expression of a sensitised response after chronic nicotine treatment. Unfortunately, the role of 5-HT(1A) receptors in mediating nicotine seeking has not yet been investigated and would seem an important area for future research. There is also evidence for nicotinic--serotonergic interactions in the acquisition of the water maze, passive avoidance, and impulsivity in the five-choice serial reaction task.

The nicotine inhaler: clinical pharmacokinetics and comparison with other nicotine treatments

Nicotine inhaled in smoke is the most rapid form of delivery of the drug. With smoking, arterial boli and high venous blood nicotine concentrations are produced within seconds and minutes, respectively. The potency of nicotine as the primary reinforcement in tobacco addiction is attributed to this rapid rate of delivery. By design, nicotine treatments reduce the rate and extent of drug delivery for weaning from nicotine during smoking cessation. Theoretically, they prevent relapse by reducing withdrawal and craving associated with the abrupt cessation of cigarettes. The nicotine inhaler treats the complexity of smoking through weaning both from the drug and from the sensory/ritual components associated with smoking. The inhaler is 'puffed' but not lit and there is considerable 'puffing' required to achieve slower rising and lower nicotine concentrations. These factors allow it to be used as a nicotine reduction treatment. One inhaler contains 10 mg of nicotine (and 1 mg of menthol) of which 4 mg of nicotine can be extracted and 2mg are systemically available. Shallow or deep 'puffing' results in similar nicotine absorption. Nicotine is delivered mainly to the oral cavity, throat and upper respiratory tract with a minor fraction reaching the lungs. This was confirmed with positron emission tomography and by assessment of arterial concentrations. A single inhaler can be used for one 20-minute period of continuous puffing or periodic use of up to 400 puffs per inhaler. With controlled puffing in laboratory testing, venous plasma nicotine concentrations from a single inhaler puffed 80 times over 20 minutes averaged 8.1 microg/L at 30 minutes. Lower concentrations of 6.4 to 6.9 microg/L have been reported for self-administration under clinical conditions. The time to peak plasma concentrations varies but is always significantly longer than with cigarette delivery. Estimates of nicotine intake from cotinine concentrations were higher than expected (60 to 70% of baseline smoking concentrations). This elevation may be due to the swallowing of nicotine and subsequent first-pass biotransformation to cotinine. In general, venous blood nicotine concentrations are considerably lower than with smoking and are within the range observed for other nicotine reduction therapies. Efficacy trials show consistent superiority of the inhaler over placebo. Despite the 'cigarette-like' appearance of the inhaler and the associated sensory/ritual elements, little treatment dependence or abuse has been reported. This is attributed to the slow rise time and low nicotine blood concentrations. The inhaler is a valuable addition to treatment of tobacco dependence and can be used alone or with other treatments.

Risk of acute first myocardial infarction and use of nicotine patches in a general population

OBJECTIVES

To determine if nicotine patches, both as prescribed and used over-the-counter, increase the risk of first myocardial infarction (MI).

BACKGROUND

Although nicotine patches improve smoking cessation rates, case reports have raised the hypothesis that they may increase the risk of MI.

METHODS

A population-based case-control study among 68 hospitals in an eight-county region surrounding Philadelphia was performed to determine if nicotine patches increase the risk of first MI. Cases were smokers (current or within the prior year) admitted to all hospitals in the region with a first MI. Controls were smokers (current or within the prior year) without prior MI selected from the same region using random-digit dialing. Data were collected by telephone interviews and chart reviews. The study had 80% power to detect an odds ratio (OR) of 2.5.

RESULTS

A total of 653 cases and 2,990 controls were interviewed. There was no association between nicotine patches and MI (OR 0.46; 95% CI: 0.09, 1.47), and the confidence interval (CI) excluded an effect from nicotine patches equal to that from cigarette smoking itself (OR < 2.5). Among those who abstained from smoking, the OR for use of nicotine patches was 0.25 (95% CI: 0.01, 1.67); among those who smoked concomitantly, the OR for patch use was 0.83 (95% CI: 0.09, 3.81). Adjustment for confounding did not alter the study's findings (OR adjusted for confounders that could mask a harmful effect of patches: 0.70; 95% CI: 0.20, 2.46).

CONCLUSIONS

Nicotine patches, as used in actual practice, do not appear to be associated with an increased risk of MI.