Gastrointestinal side effects in chronic opioid users: results from a population-based survey

BACKGROUND

Gastrointestinal side effects are commonly associated with opioid treatment for pain.

AIM

To understand gastrointestinal side effects associated with opioid treatment.

METHODS

This study was a population-based survey of adults in the US who use opioids to manage pain unrelated to cancer. Participants were recruited from an existing Web-enabled panel and a supplemental panel of individuals who previously indicated an interest in participating in Web-based surveys.

RESULTS

Overall, 2055 individuals participated in the main phase of the survey. Fifty-seven per cent of participants reported having had constipation that they associated with opioid treatment, and 49% reported constipation in the previous 4 weeks. Thirty-six per cent of participants reported new or worsening constipation in the previous 4 weeks. Thirty-three per cent of participants reported constipation as their most bothersome symptom associated with opioid treatment, 13% reported nausea, 11% abdominal pain and 10% gas. Seventy-three per cent of the participants who reported any GI symptoms did not change the dosage level or frequency of use of opioids because of adverse events, which may be explained by the fact that 72% of participants used over-the-counter laxatives and 12% a prescription laxative.

CONCLUSION

Constipation is a frequent and significant event occurring with opioid use.

Characteristics of selectors of nicotine replacement therapy

OBJECTIVE

To assess differences in demographic and smoking characteristics between smokers who have and have not used nicotine replacement therapy (NRT).

DESIGN

Mail survey of US smokers from a national research panel.

PARTICIPANTS

Smokers 18 years and over who returned a survey on smoking (n = 9630). The sample was weighted to match the US smoker population on age and sex.

MAIN OUTCOME MEASURES

Compared smokers who had/had not used NRT in a quit attempt (ever NRT use or over the counter (OTC) NRT use) on: demographic characteristics, nicotine dependence, history of craving and withdrawal, expected difficulty quitting, and self reported history of smoking related medical illness and psychopathology.

RESULTS

NRT users (both ever-users and OTC users) were more likely to be older, male, and better educated. They were also heavier smokers, had experienced more craving and withdrawal upon quitting, and scored higher on measures of dependence. These differences were evident among light smokers, and remained even when smoking rate and time to first cigarette were controlled.

CONCLUSION

Smokers who elect to use NRT differ from non-NRT users in ways that predispose them to failure in cessation. Controlling for smoking rate and time to first cigarette does not eliminate these differences, even among light smokers. These differences must be considered when comparing the effectiveness of NRT among samples of smokers who self select their treatment and are likely to bias such outcome comparisons.

Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability

Currently available nicotine replacement therapy (NRT) medications provide effective treatment for tobacco dependence, typically doubling success rates compared with placebo. A strategy for further improving the efficacy of NRT is to combine one medication that allows for passive nicotine delivery (e.g. transdermal patch) with another medication that permits ad libitum nicotine delivery (e.g. gum, nasal spray, inhaler). The rationale for combining NRT medications is that smokers may need both a slow delivery system to achieve a constant concentration of nicotine to relieve cravings and tobacco withdrawal symptoms, as well as a faster acting preparation that can be administered on demand for immediate relief of breakthrough cravings and withdrawal symptoms. This article reviews 5 published studies that have examined the effectiveness of combination NRT compared with monotherapy in providing withdrawal relief and smoking cessation, and examines other factors relevant to the promotion of combination NRT for treating tobacco dependence. The data show that there are conditions under which combinations of NRT products provide greater efficacy in relieving withdrawal and enabling cessation than monotherapy, but the findings are not robust and additional research is warranted to better understand the magnitude and generality of the benefits of combination therapy. There are also regulatory and commercial obstacles that must be considered. Nonetheless, combination NRT has the potential to provide effective treatment of tobacco dependence in persons whose dependence is refractory to currently available treatments.

Sex differences in workplace smoking policies: results from the current population survey

OBJECTIVE

To determine the prevalence of smoking policies in indoor work environments in the United States, with a special focus on sex differences in the provision of these policies.

METHOD

Information on the prevalence and restrictiveness of workplace smoking policies was obtained from 86,490 currently employed indoor workers (50,865 women and 35,625 men) 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey, a cross-sectional survey of households in all 50 states and the District of Columbia conducted between 1995 and 1996.

RESULTS

Eighty-six percent of respondents reported that their workplaces had official smoking policies, and 63% reported that their workplaces were smoke free. Women reported significantly higher rates of both official smoking policies and smoke-free workplaces than men, regardless of racial/ethnic or age group.

CONCLUSION

The overall rates of worksite smoking restrictions, including the establishment of smoke-free workplaces, were higher than those reported in earlier surveys. Disparities in coverage will need to be reduced if all workers, regardless of sex, race, age, or industry of employment, are to be protected from the demonstrated hazards of environmental tobacco smoke.

Test of "Light" cigarette counter-advertising using a standard test of advertising effectiveness

OBJECTIVE

To evaluate systematically the effectiveness of six advertising strategies (two message strategies presented in three different contexts) designed to promote smoking cessation by addressing smokers' misperceptions about Light cigarettes.

DESIGN

Smokers viewed one of six, 30 second test television concept advertisements, which varied by message (one emphasising how the sensory effects of Lights can be deceptive, the other describing the effects of vent blocking) and by ad context (non-commercial public service announcement (PSA), promotion of unbranded nicotine replacement therapy (NRT), or promotion of branded NRT). The effectiveness of each advertisement was determined using a validated advertising testing system in which ads were viewed in the context of reviewing a pilot television programme. Response to ads is assessed through shifts in subject choices of products offered as prizes before and after viewing the test advertisements. Included among the possible prizes were cigarettes and various pharmacotherapies for smoking cessation.

SUBJECTS

Daily smokers (n = 1890) of Regular (34%), Light (47%), and Ultra Light (19%) cigarettes recruited from eight US cities.

MAIN OUTCOMES MEASURES

The primary outcome of interest was the shift away from cigarettes as the selected prize following exposure to the test advertisements. Secondary outcomes of interest included movement away from Light cigarettes and movement towards assisted quitting products.

RESULTS

Smokers who saw the advertisement emphasising the sensory characteristics of Light cigarettes were more likely than subjects who saw the advertisement emphasising the effect of vent blocking to move away from cigarettes (OR = 1.97, 95% confidence interval CI 1.25 to 3.09; chi(2)(1) = 8.69, p = 0.003). Similarly, subjects who saw the advertisement framed as a PSA, rather than as a promotion for either a branded or unbranded NRT product, were also somewhat more likely to move away from cigarettes (OR = 1.51, 95% CI 0.94 to 2.40; chi(2)(1) = 2.97, p = 0.085). The effect was observed regardless of sex, age, or type of cigarette smoked.

CONCLUSIONS

Addressing smokers' sensory perceptions of Light cigarettes and presenting this information in an impartial way is likely to be an effective communication strategy for counter-marketing Light cigarettes.

Effect of filter vent blocking on carbon monoxide exposure from selected lower tar cigarette brands

Two studies were conducted to determine the effect of blocking filter vents on carbon monoxide (CO) exposure under ad lib smoking conditions. In Study 1, 12 daily cigarette smokers smoked cigarettes from the brands Now (1 mg tar by the FTC Method) and Marlboro Lights (10 mg tar) under each of two vent-blocking conditions (unblocked and finger blocked). Blocking filter vents with fingers led to an 85% increase in CO for the brand Now, but had no added effect on CO exposure from the Marlboro Lights. In Study 2, another 12 daily cigarette smokers smoked cigarettes from each of four additional brands: Carlton (1 mg tar), Now (2 mg tar), Virginia Slims Ultra-lights (5 mg tar), and Virginia Slims Lights (8 mg tar). Blocking filter vents with the lips caused all four brands to produce equal CO exposures. Blocking vents increased smokers' exposure to CO by 239% when smoking Carltons and by 44% when smoking Nows. No significant increases in CO with blocking were found for either of the Virginia Slims brands. These results suggest that the degree to which a brand is ventilated determines whether that brand is susceptible to increased CO yields as a result of vent blocking.

Smoker reactions to a "radio message" that Light cigarettes are as dangerous as Regular cigarettes

The purpose of this study was to examine in a systematic, controlled fashion the reactions of smokers to scientifically correct information about the risks of smoking Light cigarettes (about 6-15 mg tar by the FTC method). Random-digit dialing, computer-assisted telephone interviews were used to locate daily smokers of Light cigarettes. In an experimental design, smokers were randomly assigned to listen (n = 293) or not (n = 275) to a persuasive simulated radio message on the risks of Light cigarettes; 108 of those who did not listen to the message in the first part of the interview were played the message in the second part, to evaluate some repeated-measures effects. Those who heard the message were more likely to report that one Light cigarette could give a smoker the same amount of tar as one Regular cigarette and that Light cigarettes were more dangerous: 55% said the message made them think more about quitting and 46% said the message increased the amount they wanted to quit; 42% said that after hearing the message they thought Light cigarettes were more dangerous. Using the Theory of Planned Behavior, structural equation modeling analysis indicated that the message acted to increase intention to quit smoking by increasing the desire to quit smoking. Seventy-three per cent of the smokers agreed that it was important to play such messages widely on the radio; 77% agreed that there should be a warning on packs that vent blocking increases tar; 61% agreed that the location of filter vents should be marked. The majority of smokers of Light cigarettes seem to value being informed that Light cigarettes are as dangerous for them as Regular cigarettes, and this information increases their intentions to quit smoking.

Smokers' misperceptions of light and ultra-light cigarettes may keep them smoking

INTRODUCTION

This study examined smokers' understanding of the relative tar deliveries of Ultra-light, Light, and Regular cigarettes, reasons for smoking Ultra-light/Light cigarettes, and the likelihood of both quitting smoking and switching to Regular cigarettes if they came to learn that one Ultra-light/Light cigarette gave the same amount of tar as one Regular cigarette.

DESIGN

Ten- to fifteen-minute random-digit-dialed, computer-assisted telephone interviews (CATI) were conducted with both a national probability sample (n = 788) and a state random sample (n = 266) of daily smokers over the age of 18.

RESULTS

Less than 10% of smokers in the national sample and only 14% of smokers in the state sample knew that one Light cigarette could give the same amount of tar as one Regular cigarette. Less than 10% of smokers in the state sample knew that one Ultra-light cigarette could give the same amount of tar as one Regular cigarette. Thirty-two percent of the Light and 26% of the Ultra-light smokers in the national sample, and 27% of Light and 25% of Ultra-light smokers in the state sample, said they would be likely to quit smoking if they learned one Light/Ultra-light equaled one Regular.

CONCLUSION

Many Light and Ultra-light smokers are smoking these cigarettes to reduce the risks of smoking and/or as a step toward quitting. However, these smokers are unaware that one Ultra-light/Light cigarette can give them the same amount of tar and nicotine as one Regular cigarette. Many of the Ultra-light/Light smokers sampled in this study stated that they would be likely to quit if they knew this information. Mistaken beliefs about low-yield brands are reducing intentions to quit smoking.

Blocking filter vents increases carbon monoxide levels from ultralight, but not light cigarettes

Effect of vent blocking on carbon monoxide (CO) exposure from a best-selling light cigarette was examined in 12 daily cigarette smokers. Mean CO boosts were not different from each other with (a) 0% filter vents blocked (5.0 ppm), (b) vents covered with lips (4.9 ppm), (c) 50% of vents covered with tape (4.8 ppm), and (d) vents covered with a pinch of the fingertips (4.9 ppm). A second study in another 12 smokers was conducted to replicate these findings as well as earlier findings that blocking vents doubles CO intake from 1-mg tar cigarettes. While blocking half the vents with fingers significantly increased CO boost from ultralight cigarettes (2.8 vs. 5.4 ppm, p < 0.001), it did not influence boosts from light cigarettes (6.3 vs. 6.5 ppm, p = 0.8). The lowest yield cigarettes (1 mg tar) may be special. Smoking machine simulations provide poor models of human smoke intake. It is unclear whether tar and nicotine intake from light cigarettes was influenced by vent blocking.

Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the United States

OBJECTIVES

The purpose was to determine filter ventilation and the nicotine content of tobacco and their contribution to machine-smoked yields of cigarettes from the United States, Canada, and the United Kingdom.

METHODS

Ninety-two brands of cigarettes (32 American, 23 Canadian, and 37 British brands) were purchased at retail outlets in State College, Pennsylvania, United States, Toronto, Canada, and London, United Kingdom. A FIDUS FDT filter ventilation tester measured the percentage air-dilution from filter vents. High-pressure, liquid chromatography was used to measure the nicotine content of tobacco. Regression techniques were used to examine the contributions of tobacco nicotine content and filter ventilation to machine-smoked yields of tar, nicotine, and carbon monoxide (CO).

RESULTS

Ninety-four per cent of the American brands, 91% of the Canadian brands, and 79% of British brands were ventilated. The total nicotine content of tobacco and percent nicotine (by weight of tobacco) averaged 10.2 mg (standard error of the mean (SEM) 0.25, range: 7.2 to 13.4) and 1.5% (SEM 0.03, range 1.2 to 2) in the United States, 13.5 mg (SEM 0.49, range: 8.0 to 18.3) and 1.8% (SEM 0.06, range: 1.0 to 2.4) in Canada, 12.5 mg (SEM 0.33, range: 9 to 17.5) and 1.7% (SEM 0.04, range: 1.3 to 2.4) in the United Kingdom. Multiple regression analyses showed that ventilation was by far the largest factor influencing machine-smoked yields of tar, nicotine, and CO.

CONCLUSION

Filter ventilation appears to be the predominant method for reducing machine-smoked yields of tar, nicotine, and CO in three countries. However, some brands contain about twice as much nicotine (total content or percent nicotine) as do others, indicating that tobacco types or blends and tobacco castings can be used to manipulate nicotine content and nicotine delivery of cigarettes.

Individual differences in the subjective effects of the first cigarette of the day: a self-report method for studying tolerance

Some smokers are more sensitive than others to the subjective effects of cigarettes, especially the first cigarette of the day. This report explored self-reported subjective effects to the first cigarette of the day and examined the extent to which heaviness of smoking and years smoking are associated with subjective effects. In 3 independent samples (ns = 254, 116, 86). self-reports of light-headedness from the first cigarette of the day decreased with increasing heaviness of smoking and increasing the number of years smoking, suggesting that differences in responses were due to differences in chronic tolerance. Because measures of the subjective effects of drugs are useful in the study of drug response variability, this self-report item on light-headedness should be included in further research on individual differences in the subjective effects of cigarette smoking.

Smokers are unaware of the filter vents now on most cigarettes: results of a national survey

OBJECTIVE

To evaluate awareness and knowledge of cigarette filter ventilation in a national probability sample of smokers of Ultra-light, Light, and regular cigarettes.

DESIGN

Random-digit-dialling and computer-assisted telephone interviewing was used on a probability sample of daily cigarette smokers (ages 18 and above).

SUBJECTS AND SETTING

218 Smokers of Ultra-light cigarettes, 360 smokers of Light cigarettes, and 210 smokers of Regular cigarettes living in the continental United States.

MAIN OUTCOME MEASURES

Percentage of respondents indicating knowledge of the presence of filter vents and the consequences of behavioural blocking of vents.

RESULTS

Many smokers had not heard about or seen the filter holes: 43% (95% CI = 36 to 50%) of smokers of Ultra-lights, 39% (95% CI = 34 to 44%) of smokers of Lights, and 47% (95% CI = 40 to 54%) of smokers of Regulars. About two in three smokers either did not know of the existence of rings of small holes on the filters of some cigarettes, or did not know that blocking increases tar yields: 69% (95% CI = 63 to 75%) of Ultra-lights, 66% (95% CI = 61 to 71%) of Lights, and 69% (95% CI = 63 to 75%) of Regulars.

CONCLUSIONS

Smokers are generally unaware of the presence and function of filter vents-a major design feature subject to behavioural blocking by smokers and now present on most cigarettes in the United States. Smokers and policy-makers need to be informed about the presence of filter vents and how vent blocking increases tar and nicotine yields from ostensibly very low-yield cigarettes.

Measuring drug urges by questionnaire: do not balance scales

Measures designed to assess self-reported drug urges are routinely balanced; that is, they contain a relatively equal number of positively and negatively worded items. Using smoking urges as an example, we explored the effect of item wording on responses to self-report items. One hundred sixteen cigarette smokers responded to 32 positively worded statements and their 32 negatively worded counterparts adapted from the Questionnaire of Smoking Urges. For 59% of the paired statements, the negatively worded item was scored higher than the positively worded item. Significant mean differences (item means for 56% of the paired statements were significantly different at the .01 level) and only moderate correlations (mean = .54; range = -.04 to .79) between item pairs were found. Balanced scales may have greater costs than benefits in the assessment of drug urges.

Misuse of "light" cigarettes by means of vent blocking

Best-selling "light" cigarettes (9-12 mg tar, by FTC method; Federal Trade Commission, 1990) generally employ filter vents to reduce standard tar and nicotine yields. Earlier research on "ultra light" cigarettes (1-4 mg tar) showed that filter vents were blocked by human smokers leading to dramatic increases in tar and nicotine yields. An objective indicator of vent blocking was applied to a sample of 158 discarded light cigarette butts, and results indicated extreme vent blocking in 47% 27% ( +/- 8, 95% CI), some vent blocking in 26% ( +/- 8), and no vent blocking in 47% ( +/- 8). Cigarette consumers need to be informed of the risks of vent blocking as a countermeasure to the marketing of light cigarettes to health-conscious smokers.