Smoking during the night: prevalence and smoker characteristics

Dopamine D1-like receptor activation decreases nicotine intake in rats with short or long access to nicotine

The use of nicotine and tobacco products is highly addictive. The dopaminergic system plays a key role in the initiation and maintenance of nicotine intake. Dopamine D1-like receptor blockade diminishes nicotine intake in rats with daily short (1 h) access to nicotine, but little is known about the effects of dopamine receptor antagonists or agonists on nicotine intake in rats with intermittent long (23 h) access. Because of the extended access conditions and high nicotine intake, the intermittent long access procedure might model smoking and vaping better than short access models. We investigated the effects of the dopamine D1-like receptor antagonist SCH 23390 and the D1-like receptor agonist A77636 on nicotine intake in male rats with intermittent short or long access to nicotine. The rats self-administered nicotine for 5 days (1 h/day) and were then given 15 intermittent short (1 h/day) or long (23 h/day) access sessions (3 sessions/week, 0.06 mg/kg/inf). The D1-like receptor antagonist SCH 23390 decreased nicotine intake to a similar degree in rats with short or long access to nicotine. The D1-like receptor agonist A77636 induced a greater decrease in nicotine intake in the rats with long access to nicotine than in rats with short access. Treatment with A77636 induced a prolonged decrease in nicotine intake that lasted throughout the dark and light phase in the long access rats. These findings indicate that blockade and stimulation of D1-like receptors decrease nicotine intake in an intermittent long access animal model that closely models human smoking and vaping.

Development of Dependence in Smokers and Rodents With Voluntary Nicotine Intake: Similarities and Differences

INTRODUCTION

Smoking and vaping throughout adolescence and early adulthood lead to nicotine dependence. Nicotine withdrawal is associated with somatic and affective withdrawal symptoms that contribute to smoking and relapse. Affective nicotine withdrawal symptoms in humans include craving for cigarettes, depression, anxiety, trouble sleeping, and cognitive deficits.

METHODS

Herein, we review clinical studies that investigated nicotine dependence in people who smoke or vape. We also discuss studies that investigated the development of dependence in animals with oral nicotine intake, nicotine aerosol self-administration, and intravenous nicotine self-administration.

RESULTS

Clinical studies report that adolescents who smoke daily develop nicotine dependence before those who smoke infrequently, but ultimately all smokers become dependent in adulthood. Preclinical studies indicate that rats that self-administer nicotine also become dependent. Rats that self-administer nicotine display somatic withdrawal signs and affective withdrawal signs, including increased anxiety and depressive-like behavior, cognitive deficits, and allodynia. Most nicotine withdrawal signs were observed in rodents with daily (7 days/week) or intermittent long access (23-hour) to nicotine. Clinical smoking studies report symptoms of nicotine dependence in adolescents of both sexes, but virtually all preclinical nicotine self-administration studies have been done with adult male rats.

CONCLUSIONS

The role of sex and age in the development of dependence in nicotine self-administration studies remains under-investigated. However, the role of sex and age in nicotine withdrawal has been thoroughly evaluated in studies in which nicotine was administered noncontingently. We discuss the need for volitional nicotine self-administration studies that explore the gradual development of dependence during adolescence and adulthood in rodents of both sexes.

IMPLICATIONS

The reviewed clinical studies investigated the development of nicotine dependence in male and female adolescent and young adult smokers and vapers. These studies indicate that most adolescent smokers and vapers gradually become nicotine dependent. Preclinical studies with rodents show that nicotine intake in widely used self-administration models also leads to dependence. However, almost all animal studies that investigated the development of nicotine dependence have been conducted with adult male rats. To better model smoking and vaping, it is important that nicotine intake in rats or mice starts during adolescence and that both sexes are included.

Tobacco use and incident sleep parameters among a rural ageing population in South Africa

INTRODUCTION

Tobacco use may be associated with incident insomnia. The aim of the study was to investigate the association between tobacco use and incident sleep parameters in a longitudinal study in South Africa.

METHODS

Longitudinal data from two consecutive waves of middle-aged and older adults in 2014-2015 (n=5059) and 2018-2019 (n=4176) in rural South Africa were analyzed. Tobacco use and sleep parameters were assessed by self-report. The associations between tobacco use and incident sleep parameters were estimated with multivariable logistic regression.

RESULTS

The prevalence of baseline sleep parameters was poor sleep quality 6.5%, sleep disturbance 13.6%, restless sleep 32.9%, and breathing stops 7.0%. In the fully adjusted model for people without poor sleep quality at baseline, daily tobacco smoking, smoking ≥10 units of tobacco products, current tobacco use and current smokeless tobacco use did not increase the odds of incident poor sleep quality. Smoking ≥10 units of tobacco products in a day (AOR=3.83; 95% CI: 1.77-8.28), current tobacco use (AOR=1.65; 95% CI: 1.09-2.51), and daily tobacco smoking (AOR=2.16; 95% CI: 1.15-4.07), were significantly positively associated with incident sleep disturbance. Furthermore, incident restless sleep was significantly positively associated with smoking ≥10 units of tobacco products in a day (AOR=3.97; 95% CI: 1.18-13.37), current smokeless tobacco use (AOR=2.78; 95% CI: 1.17-6.62) and current tobacco use (AOR=2.00; 95% CI: 1.00-4.00). Incident breathing stops were significantly positively associated with daily smoking tobacco (AOR=2.08; 95% CI: 1.11-3.34), smoking 1-9 units of tobacco products in a day (AOR=2.17; 95% CI: 1.20-3.94), and current tobacco use (AOR=1.77; 95% CI: 1.16-2.72).

CONCLUSIONS

Higher tobacco use was independently associated with incident sleep disturbance, incident restless sleep, and incident breathing stops, but not with incident poor sleep quality.

Nighttime Waking to Smoke, Stress, and Nicotine Addiction

INTRODUCTION

Up to one-half of cigarette smokers may wake up during the night and smoke. This behavior may result in greater likelihood of cessation failure, clinically relevant sleep difficulties, and a range of health issues. Whereas the scientific literature has often attributed this behavior to nicotine dependence, up to 85% of smokers who wake at night and smoke attribute this behavior to factors other than nicotine. This study examines the relations between nicotine dependence, psychological distress, perceived stress, and waking at night to smoke.

METHODS

A total of 351 adult smokers from the Pennsylvania Adult Smoking Study (PASS) completed self-report surveys and provided saliva for the evaluation of cotinine values. Survey instruments included measures of nicotine addiction, perceived stress, a broad measure of global psychological distress, and a range of demographic factors.

RESULTS

Logistic regression demonstrated that nicotine addiction, psychological distress, and perceived stress were all related to waking at night to smoke, but cotinine levels were not. Mediation models found that psychological distress had a direct relation to waking at night to smoke, even when considering nicotine addiction and other causes of sleep disturbances (e.g., apnea and chronic physical pain). Alternative moderation and mediation models were conducted but did not support other plausible associations between variables.

CONCLUSIONS

Waking at night to smoke is likely the result of both nicotine dependence and psychological distress. Given that cotinine levels were not associated with waking at night, the mechanisms of how nicotine dependence may affect waking at night need further investigation.

Validity of the DSM-5 tobacco use disorder diagnostics in adults with problematic substance use

BACKGROUND

DSM-5 tobacco use disorder (TUD) nosology differs from DSM-IV nicotine dependence (ND) by including craving and DSM-IV abuse criteria, a lower threshold (≥ 2 criteria), and severity levels (mild; moderate; severe). We assessed concurrent and prospective validity of the DSM-5 TUD diagnosis and severity and compared validity with DSM-IV ND diagnosis.

METHODS

The sample included U.S. adults with current problematic substance use and past year cigarette smoking (N = 396). Baseline assessment collected information on DSM-IV ND and DSM-5 TUD criteria, smoking-related variables, and psychopathology. Over the following 90 days, electronic daily assessments queried smoking and cigarette craving. Variables expected to be related to TUD were validators: cigarette consumption, cigarette craving scale, Fagerström Test for Nicotine Dependence, and psychiatric disorders. Regression models estimated the association of each validator with DSM-5 TUD and severity levels, and differential association between DSM-5 TUD and DSM-IV ND diagnoses.

RESULTS

DSM-5 TUD and DSM-IV ND were associated with most baseline validators (p-values < 0.05), with significantly stronger associations with DSM-5 TUD for number of days smoked (p = 0.023) and cigarette craving scale (p = 0.007). Baseline DSM-5 TUD and DSM-IV ND predicted smoking and craving on any given day during follow-up, with stronger associations for DSM-5 TUD (association difference [95% CI%]: any smoking, 0.53 [0.27, 0.77]; number of cigarettes smoked, 1.36 [0.89, 1.78]; craving scale, 0.19 [0.09, 0.28]). Validators were associated with TUD severity in a dose-dependent manner.

CONCLUSION

DSM-5 TUD diagnostic measures as operationalized here demonstrated concurrent and prospective validity. Inclusion of new criteria, particularly craving, improved validity and clinical relevance.

Smoke at night and sleep worse? The associations between cigarette smoking with insomnia severity and sleep duration

OBJECTIVE

Insomnia is a clinically verified nicotine withdrawal symptom. As nicotine is a stimulant, it is plausible that smoking at night could disturb sleep more than smoking at earlier times of the day, but this remains empirically unclear. This study examined smoking status and its associations with insomnia severity and sleep duration while considering the potential role of smoking time.

METHODS

Data were derived from the Sleep and Healthy Activity Diet Environment and Socialization study, a community-based study of 1007 adults (nnonsmokers = 818; nsmokers = 189) aged 22-60 from the Philadelphia area. Smoking status and time of smoking were self-reported. Insomnia was assessed with the Insomnia Severity Index and categorized as none, mild, and moderate-to-severe. Sleep duration was assessed with one item from the National Health and Nutrition Examination Survey and categorized as very short, short, normal, and long. Ordinal and multinomial logistic regressions were used to determine the association of smoking status including smoking time with insomnia severity and sleep duration controlling for sociodemographic covariates.

RESULTS

Compared to nonsmoking, smoking was associated with experiencing increased insomnia (odds ratio = 2.5, 95% confidence interval [CI] 1.9, 3.4, P < .001) as well as very short (relative risk ratio = 1.9, 95% CI 1.1, 3.3) and short (relative risk ratio = 1.5, 95% CI 1.0, 2.3) sleep (vs normal sleep duration). Night-time smoking was significantly associated with greater insomnia and shorter sleep duration.

CONCLUSIONS

Findings provide evidence that smoking is associated with increased insomnia severity and shorter sleep duration, particularly nightly smoking. Sleep health should be considered in smoking cessation efforts.

Sleep Quality Associated with Habitual Physical Activity Level and Autonomic Nervous System of Smokers

BACKGROUND

Few studies have examined the relationship of one's habitual physical activity level and autonomic nervous system (ANS) modulation on sleep quality in smokers.

OBJECTIVE

The aim of this study was to identify changes in the sleep quality of smokers and its relation with their habitual physical activity level and ANS modulation.

METHODS

Forty-two smokers were divided into two groups according to the 50th percentile of the moderate-to-vigorous physical activity (MVPA). Sleep quality was assessed using the Mini-sleep Questionnaire, and ANS modulation was assessed by indices of heart rate variability (HRV). To examine the possible mean differences, the analysis of covariance (ANCOVA) was used, adjusted for age, sex, body composition, pack-years, beta-blockers, anxiety, and depression in log base 10, not including qualitative data, such as sex and beta-blockers. Correlations were made by using the Spearman rank correlation. The statistical significance was set at 5.

RESULTS

The smokers who were less active showed poor sleep quality (p=0.048) and insomnia (p=0.045). Furthermore, the less active group presented decreased parasympathetic modulation [HF (un; p=0.049); RMSSD (ms; p=0.047) and SD1 (ms; p=0.047)] and an increased LF (un) index (p=0.033) and LF/HF ratio (p=0.040). A positive correlation between the total Mini-sleep score with LF (un) index (r=0.317, p=0.041) and LF/HF ratio (r=0.318, p=0.040) and negative correlation with HF (un) index (r= -0.322, p=0.038).

CONCLUSIONS

Smokers with lower levels of habitual physical activity showed poor sleep quality and alterations in autonomic nervous system modulation; (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).

Tobacco smoke exposure and sleep: estimating the association of urinary cotinine with sleep quality

INTRODUCTION

A majority of studies on tobacco smoke exposure and sleep quality have relied on self-reported smoking, resulting in potential exposure misclassification and biases related to self-report. The objective of this study was to investigate associations between urinary cotinine, a biological marker of tobacco smoke exposure, and sleep quality measures, including sleep duration, sleep continuity or efficiency, sleep satisfaction and alertness during normal waking hours.

METHODS

Using data on a national sample of 10 806 adults (aged 18-79 years) from the Canadian Health Measures Survey (2007-2013), we performed binary logistic regression analyses to estimate associations between urinary cotinine concentrations and sleep quality measures, while controlling for potential confounders. Additionally, we performed ordinal logistic regression to assess the association between urinary cotinine concentrations and increased number of sleep problems.

RESULTS

Overall, 28.7% of adult Canadian survey respondents had urinary cotinine concentrations above the limit of detection (LOD), nd the prevalence of each sleep problem ranged from 5.5% to 35.6%. Elevated urinary cotinine concentrations (quartile 4 vs. <LOD) were associated with significantly higher odds of short or long sleep duration (OR = 1.41; 95% CI: 1.02-1.95; p-trend = .021), trouble falling or staying asleep (OR = 1.71; 95% CI: 1.28-2.27; p-trend = .003), sleep dissatisfaction (OR = 1.87; 95% CI: 1.21-2.89; p-trend = .011), and increased number of sleep problems (OR = 1.64; 95% CI: 1.19-2.26; p-trend = .001). Stronger associations were observed among females compared to males.

CONCLUSION

Using a biological marker of tobacco smoke exposure, our study contributes to the body of literature of toxic environmental exposures on sleep quality by supporting an association between tobacco smoke exposure and poorer sleep quality. To address the limitations of a cross-sectional study design and to better assess the temporality of tobacco smoke exposure and sleep quality, longitudinal studies are recommended.

Sleep Disturbance in Indonesia: How Much Does Smoking Contribute?

Objective: To examine the linkage between smoking and sleep disturbance in Indonesia Methods: This study used data from the 2014 Indonesia Family Life Survey (IFLS), drawn from a sample of 38,879 individuals from 15,067 households living in 262 communities. Sleep disturbance was measured by ten validated indicators of sleep quality and sleep deprivation adopted from the PROMIS (Patient Recorded Outcomes Measurement Information System), developed by the USC Center for Economic and Social Research (CESR), USA. Hierarchical ordered logistic regression was used to account for unobserved factors in village communities. Results: In 2014, the prevalence of smoking in Indonesia remained high at thirty-two percent of the population, or about ninety million active smokers. Nearly half of smokers were young adult males. Eight of every ten males who reported sleep disturbance were smokers. Current smokers' odds of facing sleep disturbance were almost one-and-one-half times higher than those of nonsmokers (OR = 1.39, p-value < 0.01), and among heavy smokers, the odds were almost double (OR = 1.91, p-value < 0.01). These findings were controlled for stressors, chronic diseases, social support and sociodemographic characteristics as well as unobserved factors in village communities. Conclusion: The substantial relationship between smoking and sleep disturbance suggests that policies that address the issue of sleep disturbance through preventing tobacco use among young adults should be a public health priority in Indonesia.

Relationship Between Nicotine Intake and Reward Function in Rats With Intermittent Short Versus Long Access to Nicotine

INTRODUCTION

Tobacco use improves mood states and smoking cessation leads to anhedonia, which contributes to relapse. Animal studies have shown that noncontingent nicotine administration enhances brain reward function and leads to dependence. However, little is known about the effects of nicotine self-administration on the state of the reward system.

METHODS

To investigate the relationship between nicotine self-administration and reward function, rats were prepared with intracranial self-stimulation electrodes and intravenous catheters. The rats were trained on the intracranial self-stimulation procedure and allowed to self-administer 0.03 mg/kg/infusion of nicotine. All rats self-administered nicotine daily for 10 days (1 hour/day) and were then switched to an intermittent short access (ShA, 1 hour/day) or long access (LgA, 23 hour/day) schedule (2 days/week, 5 weeks).

RESULTS

During the first 10 daily, 1-hour sessions, nicotine self-administration decreased the reward thresholds, which indicates that nicotine potentiates reward function. After switching to the intermittent LgA or ShA schedule, nicotine intake was lower in the ShA rats than the LgA rats. The LgA rats increased their nicotine intake over time and they gradually consumed a higher percentage of their nicotine during the light phase. The nicotinic acetylcholine receptor (nAChR) antagonist mecamylamine induced a larger increase in reward thresholds (ie, anhedonia) in the LgA rats than the ShA rats. In the LgA rats, nAChR blockade with mecamylamine decreased nicotine intake for 2 hours and this was followed by a rebound increase in nicotine intake.

CONCLUSIONS

A brief period of nicotine self-administration enhances reward function and a high level of nicotine intake leads to dependence.

IMPLICATIONS

These animal studies indicate that there is a strong relationship between the level of nicotine intake and brain reward function. A high level of nicotine intake was more rewarding than a low level of nicotine intake and nicotine dependence was observed after long, but not short, access to nicotine. This powerful combination of nicotine reward and withdrawal makes it difficult to quit smoking. Blockade of nAChRs temporarily decreased nicotine intake, but this was followed by a large rebound increase in nicotine intake. Therefore, nAChR blockade might not decrease the use of combustible cigarettes or electronic cigarettes.

Sleep as a Target for Optimized Response to Smoking Cessation Treatment

Declining national rates of current tobacco use to an all-time low of 15.1% represents a public health victory. Undermining this progress, however, are smoking rates of up to 50% among high-risk, low-income populations. Current FDA-approved treatments for nicotine dependence are ineffective with between 70-95% of treatment-seekers relapsing within the first year of attempted abstinence. Thus, identification of novel intervention targets to optimize response to currently available treatments for nicotine dependence is a critical next step. One such target may be sleep insomnia. Insomnia is a clinically verified nicotine withdrawal symptom but, to date, addressing insomnia or other sleep disturbance symptoms as an adjunctive smoking cessation therapy has yet to be fully considered. To this end, this manuscript presents a narrative review of: (1) sleep continuity and architecture in smokers versus nonsmokers; (2) effects of nicotine abstinence on sleep; (3) possible mechanisms linking sleep with smoking cessation outcomes; (4) plausible adjunctive sleep therapies to promote smoking cessation; (5) possible treatments for unhealthy sleep in smokers; and (6) directions for future research. Taken together, this will provide conceptual support for sleep therapy as an adjunctive treatment for smoking cessation.

Implications

This narrative literature review presents a comprehensive discussion of the relationship between habitual sleep and cigarette smoking. The extent to which unhealthy sleep in smokers may be a viable intervention target for promoting response to smoking cessation treatment is considered. Ultimately, this review provides conceptual support for sleep therapy as an adjunctive treatment for smoking cessation.

Educational attainment & quitting smoking: A structural equation model approach

In the United States, disparities in smoking prevalence and cessation by socioeconomic status are well documented, but there is limited research on reasons why and none conducted in a national sample assessing multiple potential mechanisms. We identified smoking and cessation-related behavioral and environmental variables associated with both educational attainment and quitting success. We used a structural equation model of cross-sectional data from respondents ≥25 years from the United States 2010-2011 Tobacco Use Supplement-Current Population Survey. Quitting success was defined as former (n = 2607) versus continuing smokers (n = 7636); categories of educational attainment were ≤high school degree, some college/college degree, and advanced degree. Results indicated that using nicotine replacement therapy (NRT) >1 month and having a home smoking restriction were associated with both educational attainment and quitting success. Those with lower educational attainment versus those with an advanced degree were less likely to report using NRT >1 month (≤high school: β = -0.50, p < 0.001; college: β = -0.24, p = 0.019). Use of NRT >1 month, in turn, was positively associated with quitting success (β = 0.25, p < 0.001). Those with lower educational attainment were also less likely to report a home smoking restriction (≤high school: β = -0.42, p < 0.001; college: β = -0.21, p = 0.009). Having a home smoking restriction was positively associated with quitting success (β = 0.50, p < 0.001). Results were similar with income substituted for education. Using NRT >1 month and having a home smoking restriction are two strategies that may explain the association between low education and lower cessation success; these strategies should be further tested for their potential ability to mitigate this association.

Transitioning from adequate to inadequate sleep duration associated with higher smoking rate and greater nicotine dependence in a population sample

INTRODUCTION

Inadequate sleep (≤6 and ≥9h) is more prevalent in smokers than non-smokers but the extent to which sleep duration in smokers relates to smoking behaviors and cessation outcomes, is not yet clear. To begin to address this knowledge gap, we investigated the extent to which sleep duration predicted smoking behaviors and quitting intention in a population sample.

METHODS

Data from current smokers who completed the baseline (N=635) and 5-year follow-up (N=477) assessment in the United Kingdom Biobank cohort study were analyzed. Multivariable regression models using smoking behavior outcomes (cigarettes per day, time to first cigarette, difficulty not smoking for a day, quitting intention) and sleep duration (adequate (7-8h) versus inadequate (≤6 and ≥9h) as the predictor were generated. All models adjusted for age, sex, race, and education.

RESULTS

Worsening sleep duration (adequate to inadequate) predicted a more than three-fold higher odds in increased cigarettes per day (OR=3.18; 95% CI=1.25-8.06), a more than three-fold increased odds of not smoking for the day remaining difficult (OR=3.90; 95% CI=1.27-12.01), and a >8-fold increased odds of higher nicotine dependence (OR=8.98; 95% CI=2.81-28.66). Improving sleep duration (i.e., inadequate to adequate sleep) did not predict reduced cigarette consumption or nicotine dependence in this population sample.

CONCLUSION

Transitioning from adequate to inadequate sleep duration may be a risk factor for developing a more "hard-core" smoking profile. The extent to which achieving healthy sleep may promote, or optimize smoking cessation treatment response, warrants investigation.

Smoking, Screen-Based Sedentary Behavior, and Diet Associated with Habitual Sleep Duration and Chronotype: Data from the UK Biobank

BACKGROUND

Sleep duration has been implicated in the etiology of obesity but less is known about the association between sleep and other behavioral risk factors for cardiovascular disease.

PURPOSE

The aim of this study was to examine the associations among sleep duration, chronotype, and physical activity, screen-based sedentary behavior, tobacco use, and dietary intake.

METHODS

Regression models were used to examine sleep duration and chronotype as the predictors and cardiovascular risk factors as outcomes of interest in a cross-sectional sample of 439,933 adults enrolled in the UK Biobank project.

RESULTS

Short sleepers were 45 % more likely to smoke tobacco than adequate sleepers (9.8 vs. 6.9 %, respectively). Late chronotypes were more than twice as likely to smoke tobacco than intermediate types (14.9 vs. 7.4 %, respectively). Long sleepers reported 0.61 more hours of television per day than adequate sleepers. Early chronotypes reported 0.20 fewer daily hours of computer use per day than intermediate chronotypes. Early chronotypes had 0.25 more servings of fruit and 0.13 more servings of vegetables per day than late chronotypes.

CONCLUSIONS

Short and long sleep duration and late chronotype are associated with greater likelihood of cardiovascular risk behaviors. Further work is needed to determine whether these findings are maintained in the context of objective sleep and circadian estimates, and in more diverse samples. The extent to which promoting adequate sleep duration and earlier sleep timing improves heart health should also be examined prospectively.

Baseline sleep quality is a significant predictor of quit-day smoking self-efficacy among low-income treatment-seeking smokers

Compared to non-smokers, smokers have an increased risk for poor sleep quality, which could undermine confidence to quit. This study examined whether baseline sleep quality was associated with quit-day smoking self-efficacy among smokers enrolled in a smoking cessation trial. Treatment-seeking low-income smokers were randomized to either a low-intensity physical activity integrated with standard smoking cessation intervention or standard care cessation only. Poor sleep quality was significantly associated with lower quit-day (week 4) smoking self-efficacy (β = -0.61; standard error = 8.1; p = .03). Over half the samples (53%) reported poor sleep quality, thus addressing baseline sleep quality is an important consideration in smoking cessation programs.

Emotion dysregulation explains the relation between insomnia symptoms and negative reinforcement smoking cognitions among daily smokers

INTRODUCTION

Insomnia co-occurs with smoking. However, mechanisms that may explain their comorbidity are not well known.

METHOD

The present study tested the hypothesis that insomnia would exert an indirect effect on negative reinforcement smoking processes via emotion dysregulation among 126 adult non-treatment seeking daily smokers (55 females; Mage=44.1years, SD=9.72). Negative reinforcement smoking processes included negative reinforcement smoking outcome expectancies, negative reinforcement smoking motives, and two negative expectancies from brief smoking abstinence (somatic symptoms and harmful consequences).

RESULTS

Insomnia symptoms yielded a significant indirect effect through emotion dysregulation for negative reinforcement smoking outcome expectancies, negative reinforcement smoking motives, and harmful consequences expectancies from brief smoking abstinence. In contrast to prediction, however, insomnia was not associated with somatic symptom expectancies from brief smoking abstinence through emotion dysregulation.

CONCLUSIONS

These data may suggest that the indirect effect of emotion dysregulation is more relevant to cognitive-affective negative reinforcement processes rather than somatic states. Overall, the present findings contribute to a growing body of literature linking emotion dysregulation as an explanatory mechanism for insomnia and smoking and uniquely extend such work to an array of clinically significant negative reinforcement smoking processes.

Associations of Night Smoking and Cravings with Quit Intentions and Attempts

Introduction: Waking at night to smoke can also serve as an indicator of dependence and treatment success.

Aims: We sought to examine whether night smoking is associated with features of smoking behaviour in a non-treatment-seeking sample of adult smokers in the general population.

Methods: Data for this study come from 1,062 current smokers obtained from an opt-in online panel in July 2010. Night smoking and night craving to smoke were assessed by questionnaire, and dependence was assessed by the Fagerstrom Test for Nicotine Dependence (FTND). Relationships were assessed using linear, logistic, and negative binomial regression.

Findings: Overall, 20.6% reported that they woke at night to smoke. FTND scores were substantially higher in those reporting night smoking. Those who reported night cravings were more likely to report quit intentions. Night smokers made 3.6 actual quit attempts (95% CI: 2.8, 4.5) per year, adjusted for other model factors, compared to 2.7 (2.2, 3.2) attempts for night cravers and 2.2 (1.8, 2.7) attempts for smokers who reported neither.

Conclusions: Overall, night smokers reported higher nicotine dependence than cravers and those who experienced neither. The current study adds to a growing literature pointing to the importance of overnight smoking as an indicator of nicotine dependence.

Nicotine dependence and sleep quality in young adults

INTRODUCTION

More cigarette smokers report poor sleep quality than non-smokers, but the association between nicotine dependence (ND) and sleep quality has not been well-characterized. The objective of this study was to describe the associations among frequency and intensity of cigarette smoking, ND symptoms, and sleep quality in young adults.

METHODS

Data on past-year smoking frequency, number of cigarettes smoked in the past month, five ND indicators (i.e., withdrawal, craving, self-medication symptoms, mFTQ, ICD-10 criteria for tobacco dependence), and sleep quality (measured with the Pittsburgh Sleep Quality Index (PSQI)) were collected in 2011-12 in self-report questionnaires completed by 405 young adult smokers (mean age 24 (0.6) years; 45% male; 45% daily smokers) participating in a longitudinal investigation of the natural course of ND. Associations between indicators of cigarette smoking, ND symptoms, and sleep quality were examined in multivariable logistic regression analyses controlling for age, sex, mother's education, and alcohol use.

RESULTS

Thirty-six percent of participants reported poor sleep quality (PSQI>5). Higher cigarette consumption (OR(95% CI), 1.03(1.001-1.05)) but not frequency of past-year smoking, more frequent withdrawal symptoms (1.05(1.004-1.10)), more frequent cravings (1.05(1.004-1.10)), higher mFTQ scores (1.14(1.02-1.27)), and endorsing more ICD-10 criteria for tobacco dependence (1.19(1.04-1.36)) were also associated with poor sleep quality.

CONCLUSION

Cigarette smoking and ND symptoms are associated with poor sleep quality in young adult smokers. Advice from practitioners to cut back on number of cigarettes smoked per day and treatment of ND symptoms may improve sleep quality in young adult smokers.

Emotion dysregulation explains relations between sleep disturbance and smoking quit-related cognition and behavior

Poor sleep quality and tobacco use are common and co-occurring problems, although the mechanisms underlying the relations between sleep disturbance and smoking are poorly understood. Sleep disturbance lowers odds of smoking cessation success and increases odds of relapse. One reason may be that sleep loss leads to emotion dysregulation, which in turn, leads to reductions in self-efficacy and quit-related problems. To address this gap, the current study examined the explanatory role of emotion dysregulation in the association between sleep disturbance and smoking in terms of (1) self-efficacy for remaining abstinent in relapse situations, (2) the presence of a prior quit attempt greater than 24h, and (3) the experience of quit-related problems among 128 adults (Mage=40.2; SD=11.0; 52.3% female) seeking treatment for smoking cessation. Results suggested that increased levels of sleep disturbance are related to emotion dysregulation which, in turn, may lead to lower levels of self-efficacy for remaining abstinent, more quit-related problems, and being less likely to have had a quit attempt of 24h or greater. Further, these indirect effects were present above and beyond variance accounted for by theoretically-relevant covariates (e.g., gender and educational attainment), suggesting that they may maintain practical significance. These findings suggest that this malleable emotional risk factor (emotion dysregulation) could serve as a target for intervention among those with poor sleep and tobacco use.

Perfil Sócio-demográfico e Clínico de uma Amostra de Fumantes Portugueses: Implicações do Sexo para a Intervenção na Cessação Tabágica

RESUMO As medidas de cessação tabágica mostram resultados positivos na diminuição da morbidade e mortalidade associadas ao consumo do tabaco. Esses programas possuem maior eficácia quando se adequam às especificidades dos tabagistas. Este estudo teve como objetivo analisar as diferenças de sexo em uma amostra de 100 fumantes portugueses, através da administração de um questionário sócio-demográfico e clínico. Observaram-se diferenças de sexo no número de cigarros consumidos por dia, no momento do dia e no contexto social de maior consumo, no residir com fumantes, na pressão social para deixar de fumar e no sono. As implicações clínicas dos resultados foram discutidas no sentido de otimizar a prestação dos serviços de saúde em contexto de cessação tabágica.

Ecological momentary assessment in the investigation of craving and substance use in daily life: a systematic review

BACKGROUND

Craving is viewed as a major determinant of relapse in persons with substance addiction, but this association remains poorly understood due to its time-limited nature and the biases associated with retrospective reporting. Ecological momentary assessment (EMA) offers new opportunities to examine both craving and substance use with strong ecological validity by collecting real-time data in daily life. This review examined all published studies using EMA to: (1) assess the link between craving and substance use; and (2) identify relevant moderators of craving among substance users.

METHODS

We searched PubMed and PsycInfo databases up to October 31, 2013.

RESULTS

Ninety-one studies were selected, involving mostly tobacco smokers (73%). A majority of studies (92%) reported a positive relationship between craving and substance use, concurrently and prospectively, and among users with different levels of use for both legal and illegal substances. Results suggest that craving is a stronger predictor of relapse episodes when assessed in close temporal proximity to substance use. EMA data also confirmed the influence of diverse within-person and between-person sources of variation in daily life craving reports.

CONCLUSIONS

This review provides strong support for the link between craving and substance use, and underscores the importance of the timing of assessments.

Development of a questionnaire for assessing dependence on electronic cigarettes among a large sample of ex-smoking E-cigarette users

INTRODUCTION

Electronic cigarettes (e-cigs) are becoming increasingly popular, but little is known about their dependence potential. This study aimed to assess ratings of dependence on electronic cigarettes and retrospectively compare them with rated dependence on tobacco cigarettes among a large sample of ex-smokers who switched to e-cigs.

METHODS

A total of 3,609 current users of e-cigs who were ex-cigarette smokers completed a 158-item online survey about their e-cig use, including 10 items designed to assess their previous dependence on cigarettes and 10 almost identical items, worded to assess their current dependence on e-cigs (range 0-20).

RESULTS

Scores on the 10-item Penn State (PS) Cigarette Dependence Index were significantly higher than on the comparable PS Electronic Cigarette Dependence Index (14.5 vs. 8.1, p < .0001). In multivariate analysis, those who had used e-cigs longer had higher e-cig dependence scores, as did those using more advanced e-cigs that were larger than a cigarette and had a manual button. Those using zero nicotine liquid had significantly lower e-cig dependence scores than those using 1-12 mg/ml, who scored significantly lower than those using 13 or greater mg/ml nicotine liquid (p < .003).

CONCLUSIONS

Current e-cigarette users reported being less dependent on e-cigarettes than they retrospectively reported having been dependent on cigarettes prior to switching. E-cig dependence appears to vary by product characteristics and liquid nicotine concentration, and it may increase over time.

Validity of proposed DSM-5 diagnostic criteria for nicotine use disorder: results from 734 Israeli lifetime smokers

BACKGROUND

The fifth edition of the diagnostic and statistical manual of mental disorders (DSM-5) proposes aligning nicotine use disorder (NUD) criteria with those for other substances, by including the current DSM fourth edition (DSM-IV) nicotine dependence (ND) criteria, three abuse criteria (neglect roles, hazardous use, interpersonal problems) and craving. Although NUD criteria indicate one latent trait, evidence is lacking on: (1) validity of each criterion ; (2) validity of the criteria as a set ; (3) comparative validity between DSM-5 NUD and DSM-IV ND criterion sets ; and (4) NUD prevalence.

METHOD

Nicotine criteria (DSM-IV ND, abuse and craving) and external validators (e.g., smoking soon after awakening, number of cigarettes per day) were assessed with a structured interview in 734 lifetime smokers from an Israeli household sample. Regression analysis evaluated the association between validators and each criterion. Receiver operating characteristic analysis assessed the association of the validators with the DSM-5 NUD set (number of criteria endorsed) and tested whether DSM-5 or DSM-IV provided the most discriminating criterion set. Changes in prevalence were examined.

RESULTS

Each DSM-5 NUD criterion was significantly associated with the validators, with strength of associations similar across the criteria. As a set, DSM-5 criteria were significantly associated with the validators, were significantly more discriminating than DSM-IV ND criteria, and led to increased prevalence of binary NUD (two or more criteria) over ND.

CONCLUSIONS

All findings address previous concerns about the DSM-IV nicotine diagnosis and its criteria and support the proposed changes for DSM-5 NUD, which should result in improved diagnosis of nicotine disorders.

Smoking antecedents: separating between- and within-person effects of tobacco dependence in a multiwave ecological momentary assessment investigation of adolescent smoking

INTRODUCTION

Ecological momentary assessment (EMA) investigations have shown that the antecedents of smoking vary with individual differences in tobacco dependence. This has been interpreted as indicating that the transition to dependence is characterized by an erosion of external stimulus control over smoking. Rigorously testing this requires collecting multiple waves of EMA data, which permits separation of the influence of between- and within-person tobacco dependence variation in multilevel models.

METHODS

Adolescents (n = 313, 9th or 10th grade at baseline) participated in up to 4 waves of week-long EMA assessment over the course of 2 years as part of a larger longitudinal, observational study. At each wave, participants recorded contextual features and subjective states in response to prompted diary assessments and when smoking. They completed a youth-specific form of the Nicotine Dependence Syndrome Scale at each wave.

RESULTS

In cross-sectional multilevel analyses, smoking was less contingent on alcohol/drug use and was more common at home and in the morning for adolescents with higher levels of dependence. Multiwave analyses demonstrated that these effects were largely attributable to between-person variation in dependence, although parameter estimates for intraindividual dependence × antecedent effects tended to be in the predicted direction.

DISCUSSION

Findings provided partial support for the contention that the antecedents of smoking shift as an individual progresses to higher levels of dependence. Distinctive choices concerning smoking settings also appear to reflect between-person differences in propensity to dependence. More generally, the findings illustrate the value of using multilevel modeling and repeated EMA assessments to investigate the correlates of tobacco dependence at different levels of analysis.

Integrating a Behavioural Sleep Intervention into Smoking Cessation Treatment for Smokers with Insomnia: A Randomised Pilot Study

INTRODUCTION

Sleep disturbance is common among cigarette smokers and predicts smoking cessation failure.

AIMS

The purpose of this study was to conduct a pilot test of whether provision of a sleep intervention might bolster smoking cessation outcomes among this vulnerable group.

METHODS

Smokers with insomnia (N = 19) seeking smoking cessation treatment were randomly assigned to receive 8 sessions over 10 weeks of either: (1) cognitive-behavioural therapy for insomnia + smoking cessation counselling (CBT-I+SC; n = 9) or (2) smoking cessation counselling alone (SC; n = 10). Counselling commenced 4 weeks prior to a scheduled quit date, and nicotine patch therapy was also provided for 6 weeks starting on the quit date.

RESULTS

There was no significant effect of counselling condition on smoking cessation outcomes. Most participants had difficulty initiating and maintaining smoking abstinence in that 7-day point prevalence abstinence rates at end of treatment (CBT-I+SC: 1/7, 14%; SC: 2/10, 20%) and follow-up (CBT-I+SC: 1/7, 14%; SC: 0/10, 0%) were low for both conditions. CBT-I+SC participants reported improvements in sleep efficiency, quality, duration and insomnia symptoms. Sleep changes were not associated with the likelihood of achieving smoking abstinence.

CONCLUSIONS

This randomised pilot study suggests that behavioural interventions may improve sleep among smokers with insomnia, but a larger sample is needed to replicate this finding and evaluate whether these changes facilitate smoking cessation.

Characteristics and smoking patterns of intermittent smokers

Current models of smoking and dependence assume a need to smoke at regular intervals to maintain nicotine levels, yet about 25% of adult smokers do not smoke daily. This subset of intermittent smokers (ITS) has gone largely unexamined. In this study, we describe the demographics, smoking history, and smoking behavior of ITS (n = 282; 50.2% male) in comparison to daily smokers (DS; n = 233; 60.7% male). Within ITS, we also compare "converted" ITS (CITS), who had previously smoked daily, with "native" ITS (NITS). On average, ITS were 34.66 years of age, and had smoked 42,850 cigarettes in the course of an average of 18 years of smoking. They smoked an average of 4.38 days per week, consuming 4.39 cigarettes a day on smoking days, and demonstrated considerable day-to-day variability in cigarette consumption. Almost half of ITS had Fagerstrom Test of Nicotine Dependence scores of 0, indicating no dependence. Compared to DS, ITS were more likely to cite alcohol drinking, socializing, and being with other smokers as common contexts for smoking, and they also more often cited being angry or stressed. Data suggested that ITS' behavior was not explained by use of other nicotine products nor by economic constraints on smoking, nor by differences in psychological adjustment. Within ITS, CITS were heavier, more frequent, and more dependent smokers. In many respects, CITS were intermediate between NITS and DS. ITS show distinct patterns of smoking behavior that are not well explained by current models of nicotine dependence.

DSM criteria for tobacco use disorder and tobacco withdrawal: a critique and proposed revisions for DSM-5

AIMS

This paper aims to identify appropriate criteria for tobacco dependence assessment, evaluate relevant research and suggest revisions that may be incorporated into DSM-5.

METHODS

Desirable conceptual and psychometric features of tobacco dependence assessments were identified, including the types of outcomes against which such assessment should be validated. DSM-IV criteria were matched against these criteria and compared with other dependence measures.

RESULTS

DSM-IV criteria were found to be ambiguous, little used in tobacco research, and have relatively low predictive validity. Other dependence measures were found to have greater validity in the prediction of important dependence features such as relapse likelihood. Strength of urges to smoke on typical smoking days and during abstinence, markers of nicotine intake or frequency of smoking and latency to smoke soon after waking were found to be useful dependence measures.

CONCLUSION

The use and utility of DSM-5 will be enhanced by eliminating most DSM-IV criteria and adding new ones based on smoking pattern, smoking heaviness, and the severity of craving during periods of smoking and withdrawal.

Effect of night smoking, sleep disturbance, and their co-occurrence on smoking outcomes

Recent evidence suggests that smoking during the night is an indicator of nicotine dependence and predicts smoking cessation failure. Night smokers are likely to experience disturbance to their sleep cycle when they wake to smoke, but we are not aware of the prevalence of night smokers' self-reported sleep disturbance. Because sleep disturbance also predicts smoking cessation failure, we examined how the pre-cessation risk factors of night smoking and sleep disturbance, and their co-occurrence, predict smoking cessation failure in a 6-week double-blind randomized controlled trial examining whether naltrexone augments the efficacy of the nicotine patch (O'Malley et al., 2006). Smokers (N = 385) completed the Pittsburgh Sleep Quality Index (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) and a single item of waking at night to smoke pre-cessation. Smoking status was determined at weeks 1, 6, 24, and 48 weeks after quitting. The two main findings were: (a) night smokers reported significantly greater sleep disturbance than nonnight smokers; and (b) smokers with co-occurring night smoking and sleep disturbance experienced significantly greater risk for smoking than smokers with neither risk factor. Results suggest that individuals who both wake during the night to smoke and report clinically-significant sleep disturbance represent a high-risk group of smokers. Future smoking cessation treatment might incorporate strategies related to managing these smokers' sleep habits and physiological dependence on nicotine in order to bolster their cessation outcomes.

Selective blockade of the orexin-2 receptor attenuates ethanol self-administration, place preference, and reinstatement

RATIONALE

Orexin-1 receptor antagonists have been shown to block the reinforcing effects of drugs of abuse and food. However, whether blockade of orexin-2 receptor has similar effects has not been determined. We have recently described the in vitro and in vivo effects of JNJ-10397049, a selective and brain penetrant orexin-2 receptor antagonist.

OBJECTIVE

The goal of these studies was to evaluate whether systemic administration of JNJ-10397049 blocks the rewarding effects of ethanol and reverses ethanol withdrawal in rodents. As a comparison, SB-408124, a selective orexin-1 receptor antagonist, was also evaluated.

METHODS

Rats were trained to orally self-administer ethanol (8% v/v) or saccharin (0.1% v/v) under a fixed-ratio 3 schedule of reinforcement. A separate group of rats received a liquid diet of ethanol (8% v/v) and withdrawal signs were evaluated 4 h after ethanol discontinuation. In addition, ethanol-induced increases in extracellular dopamine levels in the nucleus accumbens were tested. In separate experiments, the acquisition, expression, and reinstatement of conditioned place preference (CPP) were evaluated in mice.

RESULTS

Our results indicate that JNJ-10397049 (1, 3, and 10 mg/kg, sc) dose-dependently reduced ethanol self-administration without changing saccharin self-administration, dopamine levels, or withdrawal signs in rats. Treatment with JNJ-10397049 (10 mg/kg, sc) attenuated the acquisition, expression, and reinstatement of ethanol CPP and ethanol-induced hyperactivity in mice. Surprisingly, SB-408124 (3, 10 and 30 mg/kg, sc) did not have any effect in these procedures.

CONCLUSIONS

Collectively, these results indicate, for the first time, that blockade of orexin-2 receptors is effective in reducing the reinforcing effects of ethanol.

Does effective management of sleep disorders reduce substance dependence?

Insomnia is often associated with substance dependence, with evidence suggesting that individuals seeking medical attention for sleep complaints are more likely to have drug or alcohol abuse problems than the general population. Disturbed sleep is associated with the abuse of a variety of drugs, with patients dependent on nicotine, alcohol and illicit drugs all reporting poor sleep. In addition, withdrawal from nicotine, alcohol and drugs of abuse is also associated with insomnia, and this may result in an increased risk of relapse if the sleep problems remain unresolved. Although studies suggest that the majority of pharmacological and behavioural interventions for insomnia are effective in treating sleep disturbances in dependent patients undergoing short-term drug withdrawal and short and long-term alcohol withdrawal, several questions remain unanswered. For example, little is known about the risk of relapse in abstinent drug-dependent patients experiencing withdrawal-related insomnia, the effect of insomnia treatment on nicotine withdrawal, or whether insomnia interventions prevent relapse. Participants of a workshop, held at the 6th annual meeting of The International Sleep Disorders Forum: The Art of Good Sleep in 2008, evaluated whether the effective management of sleep disorders could reduce substance dependence and the risk of relapse. Following the workshop a targeted literature review was conducted addressing this question. Data from this review that either pharmacological or cognitive behavioural treatment of insomnia could reduce the risk of relapse in substance dependence were substantially lacking. Further research is therefore required to increase our understanding of the impact of insomnia on patients with substance dependence.

Sleep disturbance as a universal risk factor for relapse in addictions to psychoactive substances

Relapse to uncontrolled use of a psychoactive substance is arguably the single most defining characteristic of an addiction. Relapse following addiction treatment is very common with serious consequences to individuals, families, and the public system of care, making predictors of relapse a highly significant area of study. Before the turn of the century, most of the addiction treatment outcome literature focused on psychosocial predictors of relapse. More recently, investigating biological predictors of relapse specifically and treatment outcome broadly has gained momentum. This line of research has linked sleep disturbances to the risk of relapse among persons who are recovering from an alcohol addiction. Given common neurobiological and psychosocial processes in sleep and addictive behaviors, we hypothesize that the link between sleep disturbance and relapse risk observed among alcohol addiction generalizes to all other types of psychoactive substances. This hypothesis has the potential for helping develop more effective and targeted treatment approaches for persons with addiction. As initial support for the hypothesis, this paper reviews evidence on common neurobiological processes among various types of psychoactive substances that suggests sleep is a universal risk factor for relapse. A conceptual framework is also presented to articulate causal mechanisms. The paper concludes with implications for research and practice.

Cigarette-by-cigarette satisfaction during ad libitum smoking

Smoking is thought to produce immediate reinforcement, and subjective satisfaction with smoking is thought to influence subsequent smoking. The authors used ecological momentary assessment (A. A. Stone & S. Shiffman, 1994) to assess cigarette-by-cigarette smoking satisfaction in 394 heavy smokers who subsequently attempted to quit. Across 14,882 cigarettes rated, satisfaction averaged 7.06 (0-10 scale), but with considerable variation across cigarettes and individuals. Women and African American smokers reported higher satisfaction. More satisfied smokers were more likely to lapse after quitting (HR = 1.1, p < .03), whereas less satisfied smokers derived greater benefit from patch treatment to help them achieve abstinence (HR = 1.23, p < .001). Cigarettes smoked in positive moods were more satisfying, correcting for mood at the time of rating. The best predictor of subsequent smoking satisfaction was the intensity of craving prior to smoking. Understanding subjective smoking satisfaction provides insight into sources of reinforcement for smoking.