Predictors of Adherence Among Vulnerable Populations of Adults Assigned to Smoke Very Low Nicotine Content Cigarettes.

INTRODUCTION: Regulators are considering reducing the nicotine content in cigarettes to a minimally addictive level. This could particularly benefit smokers from populations vulnerable to heavy smoking and difficulties quitting. We assessed predictors of adherence among adults from vulnerable populations assigned to use very low nicotine content cigarettes (VLNCs) in randomized clinical trials, to identify characteristics of those who require additional assistance if a nicotine reduction policy were implemented. AIMS AND METHODS: Data came from three populations of vulnerable adult smokers assigned to use VLNC cigarettes (0.4 mg/g nicotine) during 12-week randomized controlled trials (n = 286): Socioeconomically disadvantaged women of reproductive age, opioid-maintained adults, and adults with affective disorders. Logistic and linear regressions modeled predictors of adherence based on changes in cotinine at week-6 and week-12 assessments relative to baseline, and as a 90% reduction in cotinine relative to baseline (full adherence: yes/no). Predictors included satisfaction with study cigarettes, craving, nicotine dependence severity, withdrawal, population membership, baseline affective-disorder symptoms, and sociodemographic characteristics. RESULTS: Dependence severity was negatively associated with both adherence measures at week 6 (p < .01), whereas increased satisfaction with study cigarettes and age were positively associated with both measures at weeks 6 and 12 (p < .01). Opioid-maintained adults exhibited reduced adherence and were less likely to reach full adherence at week 12 compared to disadvantaged women (p = .02). CONCLUSIONS: Factors associated with VLNC adherence in vulnerable populations are similar to those in the general population of smokers. Furthermore, studies are indicated investigating nicotine supplements (e.g., e-cigarettes, NRT) to support highly dependent adults faced with using VLNCs. IMPLICATIONS: This study identified factors predicting difficulty maintaining adherence to a regimen of very low nicotine content cigarettes (VLNC) among adults from vulnerable populations. Findings suggested that factors predicting difficulty maintaining adherence (greater nicotine dependence and low satisfaction with study-provided VLNC) were common across vulnerable smokers and the general population of adults who smoke. Furthermore, research should investigate alternatives to support highly dependent adults, such as pairing VLNC with supplemental, noncombusted nicotine. Some vulnerable populations (e.g., opioid-maintained adults) may be especially in need of supplemental, noncombusted nicotine.

Trend differences in men and women in rural and urban U.S. settings.

BACKGROUND: Smoking prevalence is declining at a slower rate in rural than urban settings in the United States (U.S.), and known predictors of smoking do not readily account for this trend difference. Given that socioeconomic and psychosocial determinants of health disparities accumulate in rural settings and that life-course disadvantages are often greater in women than men, we examined whether smoking trends are different for rural and urban men and women. METHOD: We used yearly cross-sectional data (n = 303,311) from the U.S. National Survey on Drug Use and Health (NSDUH) from 2007 through 2014 to compare cigarette smoking trends in men and women across rural and urban areas. Current smoking status was modelled using logistic regression controlling for confounding risk factors. RESULTS: Regression derived graphs predicting unadjusted prevalence estimates and 95% confidence bands revealed that whereas the smoking trends of rural men, urban men, and urban women significantly declined from 2007 to 2014, the trend for rural women was flat. Controlling for demographic, socioeconomic and psychosocial predictors of smoking did not explain rural women's significantly different trend from those of the other three groups. CONCLUSION: Rural women lag behind rural men, urban men and urban women in decreasing smoking, a health disparity finding that supports the need for tobacco control and regulatory policies and interventions that are more effective in reducing smoking among rural women.

A growing geographic disparity: Rural and urban cigarette smoking trends in the United States.

Rural areas of the United States have a higher smoking prevalence than urban areas. However, no recent studies have rigorously examined potential changes in this disparity over time or whether the disparity can be explained by demographic or psychosocial characteristics associated with smoking. The present study used yearly cross sectional data from the National Survey on Drug Use and Health from 2007 through 2014 to examine cigarette smoking trends in rural versus urban areas of the United States. The analytic sample included 303,311 respondents. Two regression models were built to examine (a) unadjusted rural and urban trends in prevalence of current smoking and (b) whether differences remained after adjusting for demographic and psychosocial characteristics. Results of the unadjusted model showed disparate and diverging cigarette use trends during the 8-year time period. The adjusted model also showed diverging trends, initially with no or small differences that became more pronounced across the 8-year period. We conclude that differences reported in earlier studies may be explained by differences in rural versus urban demographic and psychosocial risk factors, while more recent and growing disparities appear to be related to other factors. These emergent differences may be attributable to policy-level tobacco control and regulatory factors that disproportionately benefit urban areas such as enforcement of regulations around the sale and marketing of tobacco products and treatment availability. Strong federal policies and targeted or tailored interventions may be important to expanding tobacco control and regulatory benefits to vulnerable populations including rural Americans.

Continuing to struggle with the term "harm reduction".

I am pleased to have this opportunity to comment on Alan Leshner's Macroscopy (this issue) recommending that the term "harm reduction" be expunged from relevant professional lexicons. To the extent that this recommendation could be successfully implemented, it engenders no disagreement from me. Instead, my comments focus on how to deal with the vast world of literature and other activities that already exist around the term.

Comparison of the subjective, physiological, and psychomotor effects of atomoxetine and methylphenidate in light drug users.

This study compared the subjective, physiological, and psychomotor effects of atomoxetine and methylphenidate with placebo in healthy volunteers. Sixteen non-dependent light drug users participated in six experimental sessions, receiving placebo, atomoxetine (20, 45 and 90 mg) and methylphenidate (20 and 40 mg) using a double-blind, Latin square design. Subjective drug effects were assessed using Visual Analog Scales (VAS), the Addiction Research Center Inventory (ARCI) and Adjective Rating Scales (ARS). Psychomotor performance was evaluated using the Digit Symbol Substitution Test (DSST). Physiological measures were also collected throughout the sessions. Assessments were conducted before drug administration and 30, 60, 90, 120, 150, 180 and 240 min following dosing. Forty milligrams methylphenidate produced significant increases on the stimulant portions of the VAS and ARS and the benzedrine, amphetamine, morphine-benzedrine and lysergic acid diethylamine (LSD) subscales of the ARCI relative to placebo. Ninety mg atomoxetine was reported to be unpleasurable relative to placebo as indicated by significant increases on the 'bad' and 'sick' portions of the VAS, and on the LSD subscale of the ARCI. Compared with placebo, both methylphenidate doses significantly increased systolic blood pressure (BP) and heart rate (HR). For atomoxetine, 90 mg increased diastolic BP, 45 and 90 mg increased systolic BP, and all three doses increased HR relative to placebo. Neither compound produced significant differences from placebo on DSST performance. These results suggest that atomoxetine does not induce subjective effects similar to methylphenidate and suggest that it is unlikely that atomoxetine will have abuse liability.

A promising intervention for a daunting problem: comment on Silverman et al. (2001).

Six features of the report are commented on. First, the Therapeutic Workplace intervention described in the report represents a creative and promising new approach to drug abuse treatment. Second, to the author's knowledge, it represents the first intervention that has been shown in a randomized clinical trial to significantly reduce cocaine abuse among pregnant women. Third, the report and study are commendable for their scientific rigor. Fourth, the treatment approach is science-based, integrating concepts and principles from several behavioral science literatures. Fifth, the intervention offers a potentially practical way of extending incentive-based drug abuse treatments to community clinics. Sixth and last, the report has the potential to provoke serious thought and consideration of what more might be done to combat the daunting and related problems of chronic unemployment and drug abuse in our poorer communities.

Alcohol dependence among cocaine-dependent outpatients: demographics, drug use, treatment outcome and other characteristics.

OBJECTIVE: Concurrent dependence on alcohol is common among those seeking treatment for cocaine dependence. More information is needed about differences between those with and without concurrent alcohol dependence, including possible special treatment needs or outcome differences. METHOD: Data were obtained from 302 adults (70% men) enrolled in outpatient treatment for cocaine dependence. Individuals who did and those who did not meet criteria for alcohol dependence were compared on demographics, drug use, treatment outcome and other variables. RESULTS: With regard to cocaine use, alcoholics were more likely than nonalcoholics to report an intranasal route of administration, use of cocaine in social settings, more simultaneous use of cocaine and alcohol, and more adverse consequences of their cocaine use. With regard to alcohol use, alcoholics reported consuming alcohol more frequently and in larger amounts, had longer drinking histories and were more likely than nonalcoholics to report increases in alcohol consumption when using cocaine. Alcoholics were heavier cigarette smokers than nonalcoholics and reported more severe employment, legal, family and psychiatric problems. There were overall improvements in both groups from intake through 12 months after treatment. With regard to treatment retention and cocaine abstinence, alcoholics had better outcomes than nonalcoholics when treated with intensive behavioral counseling plus incentives, but the reverse was true when treated with control treatments. CONCLUSIONS: Compared with nonalcoholic cocaine-dependent subjects, codependent patients exhibit a wider array of problems, many of which merit professional attention. Both alcoholics and nonalcoholics exhibit substantial improvements during treatment, with alcoholics perhaps requiring extra treatment efforts for successful outcomes.

Contingent reinforcement of marijuana abstinence among individuals with serious mental illness: a feasibility study.

The feasibility of using monetary incentives to promote abstinence from marijuana use among individuals with serious mental illness was examined by using a within-subjects experimental design. Participants were 18 adults with schizophrenia or other serious mental illness who reported regular marijuana use. During 2 baseline conditions, participants received payment for submitting urine specimens independent of urinalysis results. During 3 incentive conditions, participants received varying amounts of money if urinalysis results were negative for recent marijuana use. The number of marijuana-negative specimens obtained was significantly greater during incentive than baseline conditions. These results provide evidence that marijuana use among at least some mentally ill individuals is sensitive to contingent reinforcement and support the potential feasibility of using contingency-management interventions to reduce substance abuse among the mentally ill.

Celebrating the decade of behavior: introduction to special issue.

This special issue represents a joint effort by the journal Experimental and Clinical Psychopharmacology and the American Psychological Association's Division of Psychopharmacology and Substance Abuse to celebrate the "Decade of Behavior: 2000-2100" initiative. The Decade of Behavior initiative seeks to underscore the importance of behavioral science to broadening understanding and offering solutions to many of society's most challenging problems. Contained in this special issue are commentaries by 3 Institute directors from the National Institutes of Health, 4 excellent critical reviews of various aspects of contemporary psychopharmacology research, and a series of 9 excellent original research reports. This series of articles bodes well for the health of psychopharmacology and substance abuse research and offers a fitting salute to this important initiative.

Initial abstinence and success in achieving longer term cocaine abstinence.

This study's goals were to characterize the relationship between early and longer term cocaine abstinence and assess whether increasing early abstinence increases longer term abstinence. Results from 190 cocaine-dependent outpatients were analyzed. Participants were divided into 2 conditions: (a) those treated with community reinforcement approach (CRA) plus contingent vouchers (n = 125) and (b) those treated with control treatments (n = 65). A period of sustained abstinence during treatment was associated with significantly greater odds of posttreatment abstinence, with no evidence of differences between the 2 treatment conditions in that regard. Treatment conditions differed in that CRA plus contingent vouchers increased the proportion of participants who sustained a period of during-treatment abstinence and increased abstinence during 6-month posttreatment follow-up. Devising interventions that increase the proportion of individuals who achieve an early period of sustained abstinence may be key to increasing longer term cocaine abstinence.

Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up.

This study assessed whether contingent incentives can be used to reinforce cocaine abstinence in dependent outpatients. Seventy cocaine-dependent outpatients were randomized into 2 conditions. All participants received 24 weeks of treatment and 1 year of follow-up. The treatment provided to all participants combined counseling based on the community reinforcement approach with incentives in the form of vouchers exchangeable for retail items. In 1 condition, incentives were delivered contingent on cocaine-free urinalysis results, whereas in the other condition incentives were delivered independent of urinalysis results. Abstinence-contingent incentives significantly increased cocaine abstinence during treatment and 1 year of follow-up compared with noncontingent incentives.

A within-subject comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar.

In this experiment we compared three different schedules of reinforcement for promoting and sustaining short-term drug abstinence. For pragmatic reasons, cigarette smoking was studied as an exemplar of drug self-administration. The three schedules studied were a fixed magnitude of reinforcement for abstinence, a progressive increase in magnitude of reinforcement for abstinence with a reset contingency for drug use, and a progressive increase in magnitude of reinforcement for abstinence without a reset contingency. Eighteen cigarette smokers experienced the three schedules in a counterbalanced order. Each schedule was in effect for 5 consecutive days (M-F), during which time abstinence was reinforced according to the different schedules of reinforcement. The total amount of reinforcement (money) available was the same during each condition. The progressive magnitude with a reset schedule was more effective than the other two schedules in sustaining an initial period of abstinence. These results systematically replicate and extend those from prior studies demonstrating the efficacy of schedules incorporating a progressively increasing magnitude of reinforcement with a reset contingency for sustaining initial drug abstinence, and demonstrate the importance of the reset contingency to that effect.

Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence.

Sixty individuals seeking outpatient treatment for marijuana dependence were randomly assigned to 1 of 3 treatments: motivational enhancement (M), M plus behavioral coping skills therapy (MBT), or MBT plus voucher-based incentives (MBTV). In the voucher-based incentive program, participants earned vouchers exchangeable for retail items contingent on them submitting cannabinoid-negative urine specimens. MBTV engendered significantly greater durations of documented marijuana abstinence during treatment compared with MBT and M, and a greater percentage of participants in the MBTV group compared with the MBT or M groups were abstinent at the end of treatment. No significant differences in marijuana abstinence were observed between the MBT and M groups. The positive effects of the voucher program in this study support the utility of incentive-based interventions for the treatment of substance dependence disorders including marijuana dependence.

d-amphetamine increases choice of cigarette smoking over monetary reinforcement.

RATIONALE: Psychomotor stimulants previously have been found to increase the frequency of cigarette smoking, but it is unclear whether this is due to a non-specific increase in general activity or a specific increase in the reinforcing effects of smoking. OBJECTIVES: To investigate whether d-amphetamine increases the relative reinforcing effects of cigarette smoking. METHODS: Ninety minutes after d-amphetamine (7.5, 15 mg/70 kg) or placebo administration, 13 male and female subjects participated in 3-h sessions during which they could make a maximum of 20 choices between cigarette smoking (two puffs per choice), earning money ($0.25 per choice), or neither. In separate sessions, using the same subjects, the effects of d-amphetamine on the frequency of ad libitum smoking was assessed. RESULTS: During choice sessions, d-amphetamine dose-dependently increased smoking choices from 4.2 +/- 0.6 to 5.7 +/- 0.6. During sessions in which subjects smoked ad libitum, d-amphetamine increased number of cigarettes smoked from 2.8 +/- 0.4 to 3.8 +/- 0.6. Breath carbon monoxide (CO) levels, a measure of smoke exposure, showed corresponding dose-related increases. CONCLUSIONS: These results are consistent with previous findings that d-amphetamine increases smoking and provide evidence that this effect is due to a drug-produced increase in the relative reinforcing effects of cigarette smoking.

Effects of abstinence on cigarette smoking among outpatients with schizophrenia.

The authors of this study examined the effects of brief smoking abstinence on smoking among 6 individuals with schizophrenia or schizoaffective disorder. Before 6 of 12 experimental sessions, participants were required to provide breath carbon monoxide (CO) samples indicative of smoking abstinence; before the remaining sessions, participants provided CO samples indicating no abstinence. During sessions, participants obtained smoking opportunities (2 puffs/opportunity) under either fixed ratio-1 or progressive ratio (PR) schedules of reinforcement. Abstinence increased smoking under both schedules and increased breakpoint for smoking under the PR schedule. These data offer further evidence that smoking by individuals with schizophrenia is orderly, operant behavior that is modulated, at least in part, by variables that also affect smoking in people without major mental illness.

Effects of response requirement and the availability of an alternative reinforcer on cigarette smoking by schizophrenics.

Cigarette smoking and other forms of drug abuse are more prevalent among schizophrenics than the general population. Despite the clinical importance of this problem, there has been relatively little experimental study of schizophrenic drug use. We examined under controlled laboratory conditions the effects of response requirement and the availability of an alternative (monetary) reinforcer on cigarette smoking by schizophrenics. Subjects were six heavy smokers with diagnoses of schizophrenia or schizoaffective disorder. Before each session, subjects provided carbon monoxide samples indicating recent smoking abstinence. During 3-h sessions, subjects obtained opportunities to smoke (2 puffs/opportunity) under a fixed ratio (FR) schedule of reinforcement, which varied across sessions from FR50 to FR6400. In half of the sessions, subjects also were able to earn a small amount of money ($0.25/ratio completed) under an FR400 schedule. Increasing the response requirement for smoking decreased smoking and increased smoking-maintained responding. The availability of the monetary reinforcer decreased smoking and smoking-maintained responding by approximately half. These results are consistent with those seen previously in community volunteers without major mental illness studied under the same experimental conditions, suggesting that smoking by these two populations is controlled, at least in part, by a common set of determinants.

Behavioral and emotional problems among children of cocaine- and opiate-dependent parents.

OBJECTIVE: To test associations between parental drug abuse and children's problems, children of cocaine- and opiate-dependent parents were compared with demographically matched referred and nonreferred children. METHOD: Cocaine- and opiate-dependent parents in treatment completed the Child Behavior Checklist for 410 children (218 boys, 192 girls) from ages 2 through 18 years (mean = 7.9 years). Children of drug abusers (CDAs) were demographically matched to referred (RCs) and nonreferred children (NRCs). RESULTS: RCs scored lower than CDAs and NRCs on most competence scales, and higher than CDAs and NRCs on all problem scales. CDAs scored lower than NRCs on most competence scales, and higher than NRCs on Withdrawn, Thought Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problems. Group status also predicted clinical range scores on most competence and all problem scales. CONCLUSIONS: CDAs showed more internalizing and externalizing psychopathology relative to matched NRCs, but they showed significantly less psychopathology than shown by matched RCs. CDAs are an important group to target for preventive interventions.

Contingency management. Incentives for sobriety.

Contingency management (CM), the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors, is an effective strategy in the treatment of alcohol and other drug (AOD) use disorders. Animal research provides the conceptual basis for using CM in AOD abuse treatment, and human studies have demonstrated the effectiveness of CM interventions in reducing AOD use; improving treatment attendance; and reinforcing other treatment goals, such as complying with a medication regimen or obtaining employment.

Adults seeking treatment for marijuana dependence: a comparison with cocaine-dependent treatment seekers.

Sixty-two individuals seeking treatment for marijuana dependence completed a comprehensive assessment. Sociodemographics, substance use, psychosocial functioning, psychiatric symptoms, and medical status were compared with similar data collected from 70 treatment-seeking, cocaine-dependent individuals. Substantial psychosocial and psychiatric problems were observed in both groups. In general, the marijuana group reported substance-use histories and a range of impairment comparable with the cocaine group; however, they showed less severe dependence. The marijuana group was more ambivalent and less confident about stopping their marijuana use than the cocaine group was about stopping their cocaine use. These findings indicate that treatment-seeking, marijuana-dependent individuals exhibit substantial problems and that further efforts to develop effective treatments for this population are warranted.