Withdrawal Symptoms among Cigarette and Waterpipe Smokers: A Study in Natural Setting

Background: The rates of tobacco use, including cigarette and waterpipe smoking, are surging in the Eastern Mediterranean region. The use of these products causes nicotine dependence that makes even short-term tobacco abstinence difficult due to aversive symptoms. During the daytime fasting of the month of “Ramadan”, people accept significant disruption in regular activities, including tobacco smoking. Thus, daytime during Ramadan (before sunset) is likely associated with abstinence symptoms emerging among tobacco smokers. We assessed this hypothesis by measuring tobacco/nicotine abstinence symptoms and craving among smokers of cigarettes or waterpipes during Ramadan. Methods: A cross-sectional survey-based study was conducted on a convenience sample of adults. Participants were assessed for general information about tobacco smoking, dependence, and nicotine desire or craving, and withdrawal symptoms using the Minnesota Nicotine Withdrawal Scale (MNWS) and the Tiffany-Drobes Questionnaire on Smoking Urges. Results: The study sample included 632 exclusive cigarette smokers and 161 exclusive waterpipe tobacco smokers. After fasting and abstaining from tobacco during the day, approximately 75% of cigarette smokers and 20% of waterpipe smokers reported smoking within the first 30 minutes. In addition, 10% of cigarette smokers and 30% of waterpipe smokers reported smoking within the first 60 minutes. Regarding smoking urge, no significant difference was found between cigarette and waterpipe smokers. For nicotine craving and withdrawal, significant differences between cigarette and waterpipe smokers were found when comparing mean scores for each of the following items: (i) urge to smoke, (ii) craving nicotine, (iii) hunger, (iv) desire for sweets, and (v) depression/feeling blue (P-values < 0.05). Conclusion: This study provided evidence from the month of Ramadan that waterpipe smoking is associated with abstinence-induced smoking urge and withdrawal symptoms that are comparable to cigarette smoking. More interdisciplinary research must be focused on developing interventions to reduce tobacco smoking, including waterpipe.

Effects of Visual Exposure to IQOS Use on Smoking Urge and Behavior

Objectives: In this study, we examined whether visual exposure to the heated tobacco product (HTP) IQOS, which was authorized for sale by the US Food and Drug Administration in 2019, acts as a cue to increase cigarette craving and smoking behavior among smokers. Methods: Young adult smokers (N = 105) were randomly assigned to view a video depicting use of either IQOS or bottled water. Main outcomes were changes in cigarette and e-cigarette desire and latency to smoke between the groups. We also examined participants' attitudes about the actors using IQOS and drinking water in the videos. Results: Exposure to the use of IQOS acutely increased observers' ratings of smoking urge and desire for a cigarette and an e-cigarette. The IQOS cue, compared with the water cue, also produced a marginally significant shorter latency to smoke. Participants perceived actors as less likeable and friendly when using IQOS than when drinking water. Conclusions: Results showed that exposure to IQOS produced smoking urge and behavior in young adult smokers, implicating IQOS use as a smoking and vaping cue. As HTPs gain popularity, product impact on passive observers should be included in their risk-benefit profile.

Exposure to JUUL use: cue reactivity effects in young adult current and former smokers

BackgroundExposure to the use of first, second and third generations of electronic cigarettes (e-cigarettes) elicits the desire to vape and smoke among observers, as well as facilitates smoking behaviour. Given the rapid rise in the popularity of the pod mod JUUL, we examined whether observing the use of this device would elicit similar responses in smokers. Exploratory analyses were also conducted to determine whether JUUL can act as a smoking cue for former smokers.MethodsThe sample consisted of 82 young adult participants (62 current smokers and 20 former smokers approximately 1 year smoke free). The study examined their response to observing use of bottled water (control cue) and JUUL (active cue) in a controlled laboratory paradigm. Both cues were delivered by a trained study confederate under the guise of a social interaction task, and participants completed mood and desire and urge surveys precue and postcue exposures.ResultsIn current smokers, exposure to the JUUL cue increased smoking urge and desire for a cigarette, mod/vape pen and JUUL, and two-thirds chose to smoke in the behavioural analogue task. In former smokers, the JUUL cue evoked modest and transient increases in desire for a cigarette and JUUL.ConclusionsThe use of JUUL affects the user and elicits responses in observers; this study is the first to demonstrate that exposure to JUUL use may act as a smoking cue and exposure to JUUL use may affect tobacco control efforts.

Small/kiddie Cigarette Packaging Size and Its Impact on Smoking: A Systematic Review

Background:Kiddie/small packs contain less than 20 cigarette sticks in a pack.Kiddie packs were introduced by the tobacco industry to support moderation and encourage quit smoking among heavy smokers although this may in turn encourage underage smoking. Smaller packs may suggest lower costs and this may increase affordability among the younger generation. This concern has causedmany countries to ban the sale of single cigarette sticks or kiddie packs. Hence, a systematic review was conducted to identify the impact of kiddie packs on smoking as compared to regular cigarette packaging in the general population.Methods:A database search was conductedin PubMed, EMBASE, CENTRAL, Web of Science and Scopus up to31stJanuary 2020. Other sources namely Google Scholar, as well as Journal of Substance Use and Tobacco Control were also searched.The results were analysed qualitatively, under four groups: initiation of smoking;urge /tendency to buy cigarettes; prevalence of smoking and attempt to reduce cigarette consumption. The methodological quality of all articles that were includedwas determined using a validated 16-item quality assessment tool (QATSDD). The literature search identified 2253 articles, of which20articles had met theinclusion criteria. Discussion:Articles that we reviewed had some evidence that kiddie packs increase the urge/tendency to buy cigarettes and also increase the attempt to reduce cigarette consumption. However, we found no evidence on theimpact of kiddie packs on the initiation of smoking and the prevalence of smoking. The average quality score for all papers was 34.1%.Given the diverse study settings of the articles and despite the challenges of the methodological quality of some papers, this review will provideevidence that kiddie packs increase urge/tendency to buy cigarettes and also increase the attempt to reduce cigarette consumption. However, since most studies were of low quality, further high-quality studies are needed to come to a firm conclusion of the impact of kiddie packs on smoking.Systematic review registration: PROSPEROCRD42018102325

Using Mobile Health Tools to Assess Physical Activity Guideline Adherence and Smoking Urges: Secondary Analysis of mActive-Smoke

Background Rates of cigarette smoking are decreasing because of public health initiatives, pharmacological aids, and clinician focus on smoking cessation. However, a sedentary lifestyle increases cardiovascular risk, and therefore, inactive smokers have a particularly enhanced risk of cardiovascular disease. Objective In this secondary analysis of mActive-Smoke, a 12-week observational study, we investigated adherence to guideline-recommended moderate-to-vigorous physical activity (MVPA) in smokers and its association with the urge to smoke. Methods We enrolled 60 active smokers (≥3 cigarettes per day) and recorded continuous step counts with the Fitbit Charge HR. MVPA was defined as a cadence of greater than or equal to 100 steps per minute. Participants were prompted to report instantaneous smoking urges via text message 3 times a day on a Likert scale from 1 to 9. We used a mixed effects linear model for repeated measures, controlling for demographics and baseline activity level, to investigate the association between MVPA and urge. Results A total of 53 participants (mean age 40 [SD 12] years, 57% [30/53] women, 49% [26/53] nonwhite, and 38% [20/53] obese) recorded 6 to 12 weeks of data. Data from 3633 person-days were analyzed, with a mean of 69 days per participant. Among all participants, median daily MVPA was 6 min (IQR 2-13), which differed by sex (12 min [IQR 3-20] for men vs 3.5 min [IQR 1-9] for women; P=.004) and BMI (2.5 min [IQR 1-8.3] for obese vs 10 min [IQR 3-15] for nonobese; P=.04). The median total MVPA minutes per week was 80 (IQR 31-162). Only 10% (5/51; 95% CI 4% to 22%) of participants met national guidelines of 150 min per week of MVPA on at least 50% of weeks. Adjusted models showed no association between the number of MVPA minutes per day and mean daily smoking urge (P=.72). Conclusions The prevalence of MVPA was low in adult smokers who rarely met national guidelines for MVPA. Given the poor physical activity attainment in smokers, more work is required to enhance physical activity in this population.

Using Mobile Health Tools to Assess Physical Activity Guideline Adherence and Smoking Urges: Secondary Analysis of mActive-Smoke (Preprint)

BACKGROUND Rates of cigarette smoking are decreasing because of public health initiatives, pharmacological aids, and clinician focus on smoking cessation. However, a sedentary lifestyle increases cardiovascular risk, and therefore, inactive smokers have a particularly enhanced risk of cardiovascular disease. OBJECTIVE In this secondary analysis of mActive-Smoke, a 12-week observational study, we investigated adherence to guideline-recommended moderate-to-vigorous physical activity (MVPA) in smokers and its association with the urge to smoke. METHODS We enrolled 60 active smokers (≥3 cigarettes per day) and recorded continuous step counts with the Fitbit Charge HR. MVPA was defined as a cadence of greater than or equal to 100 steps per minute. Participants were prompted to report instantaneous smoking urges via text message 3 times a day on a Likert scale from 1 to 9. We used a mixed effects linear model for repeated measures, controlling for demographics and baseline activity level, to investigate the association between MVPA and urge. RESULTS A total of 53 participants (mean age 40 [SD 12] years, 57% [30/53] women, 49% [26/53] nonwhite, and 38% [20/53] obese) recorded 6 to 12 weeks of data. Data from 3633 person-days were analyzed, with a mean of 69 days per participant. Among all participants, median daily MVPA was 6 min (IQR 2-13), which differed by sex (12 min [IQR 3-20] for men vs 3.5 min [IQR 1-9] for women; <italic>P</italic>=.004) and BMI (2.5 min [IQR 1-8.3] for obese vs 10 min [IQR 3-15] for nonobese; <italic>P</italic>=.04). The median total MVPA minutes per week was 80 (IQR 31-162). Only 10% (5/51; 95% CI 4% to 22%) of participants met national guidelines of 150 min per week of MVPA on at least 50% of weeks. Adjusted models showed no association between the number of MVPA minutes per day and mean daily smoking urge (<italic>P</italic>=.72). CONCLUSIONS The prevalence of MVPA was low in adult smokers who rarely met national guidelines for MVPA. Given the poor physical activity attainment in smokers, more work is required to enhance physical activity in this population.

Assessing Cigarette Craving With a Squeeze

We evaluated the utility of a nonverbal, “visceral” measure of cigarette craving (squeezing a handheld dynamometer). Nicotine-deprived daily smokers ( N = 202) underwent a cued (lit cigarette) cigarette-craving manipulation and recorded smoking urge in one of four conditions: (a) report urge using a traditional self-report rating scale (verbal measure) and then indicate urge by squeezing a dynamometer, (b) indicate urge by squeezing and then report urge verbally, (c) indicate urge only by squeezing, or (d) report urge only verbally. As hypothesized, the squeeze measure detected increases in urge during cue exposure, correlated with verbal urge, and predicted subsequent smoking motivation as indexed by smoking latency. Order effects were not observed, indicating that the squeeze measure was predictive of smoking motivation regardless of whether it was administered before or after a verbal urge measure. Squeeze measures may be viable additions to the measurement toolkit for assessing urge and other visceral states.

Trait Persistence Moderates the Association between Gender and Change in Smoking Urge Across Repeated Cue Exposure Trials

Previous research suggests that persistence, an individual difference characteristic representing the ability and willingness to maintain engagement in challenging or aversive contexts, may relate to smoking relapse. Improving understanding of the persistence-relapse risk association could guide improvements in behavioural interventions. We explored whether persistence and gender related to change in smoking urges across multiple cue exposure trials (an analogue of extinction learning and relapse risk). Participants included abstinent smokers who completed 12 massed, 5-minute smoking cue exposure trials using guided imagery as well as olfactory, tactile, visual and motor cues associated with smoking. We used multilevel logistic growth curve modelling to explore predictor associations with change in urge. Results suggested that gender related to urge whereby males showed greater initial and sustained reactivity than females. Persistence was not associated with female urge trajectories. However, compared to males with high persistence, males with low persistence evidenced sustained urge reactivity over time. Results suggest that greater persistence relates to reduction of conditioned responding (e.g., urges) among abstinent male smokers when exposure trials include complex cues most closely related to nicotine self-administration. Because persistence is modifiable, males with low persistence may benefit from interventions that include elements designed to increase persistence in urge eliciting situations.

Second Generation Electronic Nicotine Delivery System Vape Pen Exposure Generalizes as a Smoking Cue

Introduction Second generation electronic nicotine delivery systems (ENDS; also known as e-cigarettes, vaporizers or vape pens) are designed for a customized nicotine delivery experience and have less resemblance to regular cigarettes than first generation “cigalikes.” The present study examined whether they generalize as a conditioned cue and evoke smoking urges or behavior in persons exposed to their use. Methods Data were analyzed inN = 108 young adult smokers (≥5 cigarettes per week) randomized to either a traditional combustible cigarette smoking cue or a second generation ENDS vaping cue in a controlled laboratory setting. Cigarette and e-cigarette urge and desire were assessed pre- and post-cue exposure. Smoking behavior was also explored in a subsample undergoing a smoking latency phase after cue exposure (N = 26). Results The ENDS vape pen cue evoked both urge and desire for a regular cigarette to a similar extent as that produced by the combustible cigarette cue. Both cues produced similar time to initiate smoking during the smoking latency phase. The ENDS vape pen cue elicited smoking urge and desire regardless of ENDS use history, that is, across ENDS naїve, lifetime or current users. Inclusion of past ENDS or cigarette use as covariates did not significantly alter the results. Conclusions These findings demonstrate that observation of vape pen ENDS use generalizes as a conditioned cue to produce smoking urge, desire, and behavior in young adult smokers. As the popularity of these devices may eventually overtake those of first generation ENDS cigalikes, exposure effects will be of increasing importance. Implications This study shows that passive exposure to a second generation ENDS vape pen cue evoked smoking urge, desire, and behavior across a range of daily and non-daily young adult smokers. Smoking urge and desire increases after vape pen exposure were similar to those produced by exposure to a first generation ENDS cigalike and a combustible cigarette, a known potent cue. Given the increasing popularity of ENDS tank system products, passive exposures to these devices will no doubt increase, and may contribute to tobacco use in young adult smokers.