Vaping was a hot topic at the 2019 Annual Meeting of the Society for Research on Nicotine or Tobacco (SRNT) held at the Hilton Union Square in San Francisco, as use of vaping products have ballooned across America and researchers have fresh findings to share. One of them was UW-CTRI Associate Director of Research Dr. Megan Piper, who participated in a symposium on vaping called Innovative Methods for Research on E-cigarettes.
Piper discussed the need to understand the construct of e-cigarette dependence, and how it relates to other important constructs (such as heaviness of use and the ability to quit vaping). She presented on the reliability and validity of three e-cigarette dependence measures: the E-cigarette Fagerstrom Test of Nicotine Dependence–“that time to first cigarette in the morning measure is gold for combustible cigarettes,” Piper said, referring to its ability to predict who can and cannot quit. But it is critical to understand whether it works as well for measuring e-cigarette dependence, she said. Piper reviewed data on the E-cigarette Wisconsin Inventory of Smoking Dependence Motives and Penn State Electronic Cigarette Dependence Index using data from two longitudinal observational cohorts (UW and University of Illinois-Chicago). There was a correlation between time to first e-cigarette and other dependence measures, even for dependence measures that didn’t specifically ask about that. Those with higher vaping dependence were more likely to still be vaping one year later. All three measures had strong, concurrent construct, and predictive validity.
Some SRNT presentations on vaping showed promise in helping smokers to switch from combustibles to vaping, with the hope that this would reduce harm. Results, though, were modest. For example, in the largest study to date examining vaping as a means to quit smoking combustibles, researchers in New Zealand gave 1,124 participants either 21 mg nicotine patch and 18 mg vapes, or 21 mg patch plus 0 mg vapes, or patch only. No payment or coaching was involved. Seven percent of those on active vapes quit, while 4 percent on placebo vapes quit, and two percent on just the patch quit.
Others, such as Dr. Irfan Rahman of Rochester University, discussed how Juul devices heat nicotine plus benzoic acid and flavorings to deliver nicotine in a way that is a smoother and less bitter experience for users. Ten puffs on a Juul delivers about 0.86 mg of nicotine, he said, as read by a machine. For comparison, an average cigarette delivers about 1.0 mg of nicotine as read by machine. Sourin, another popular vaping device, delivers about 0.25 mg of nicotine as read by machine. What isn’t known is how much nicotine an actual human consumes from both products.
In that same symposium, experts discussed findings that Juul can cause inflammation in bronchial epithelial cells and shows signs of toxicity and inflammation in monocytes (white blood cells). As little as 15 puffs can cause oxidative stress, they said, though that varies by flavor.
Piper also presented a poster, Changes in Use Patterns Among Smokers and Dual Users of cigarettes and e-cigarettes. She found that, in this community sample, dual use of vaping and smoking was unstable—only half of dual users continued using both products for a year. This is consistent with PATH data. Slightly more dual users quit smoking than smokers, but small sample size, attrition, and lack of random assignment compromises strong conclusions.
Piper’s two presentations among 17 total by UW-CTRI employees at SRNT. Here is a rundown of the others:
Other Symposia and Presentations
1. Leveraging Epidemiological, Ecological, and Clinical Data to Improve Smoking Cessation Rates Among Heavy-Drinking Smokers. Symposium. Dr. Sara Dermody, chair. Dr. Sherry McKee, discussant. Dr. Adrienne Johnson and Dr. Jesse Kaye, two of the presenters.
Kaye presented findings from a smoking-cessation trial of varenicline vs. nicotine patch vs. combo-nicotine-replacement that addressed the influence of baseline alcohol use on smoking-cessation outcomes and how those associations varied as a function of treatment conditions. There were no differences in abstinence at 26 weeks among the general study participants. (Baker et al, JAMA, 2016) At four weeks, moderate drinkers were more likely to be abstinent from smoking but, by end of treatment, the differences were no longer significant. There were no significant treatment effects by drinker type.
Using data from the same trial of daily smokers interested in quitting, Johnson found smokers with lifetime co-morbid alcohol and substance use disorder diagnoses are particularly at risk for smoking relapse. Further, this group had elevated overall nicotine dependence levels, which were driven by differences in secondary dependence motives (e.g., affiliative attachment, affective reinforcement, etc.).
2. SRNT Treasurer’s Report. Dr. Megan Piper, presenter. SRNT Members’ Meeting.
3. New Strategies to Increase the Delivery of Effective Tobacco Cessation Treatment in Primary Care. Symposium. Madeline Oguss and Dr. Melanie Boeckmann, co-chairs. Dr. Tanya Schlam and Madeline Oguss, two of the presenters. Dr. Anne Joseph, discussant.
Oguss examined the impact of modifying the electronic health record (EHR) in primary care clinics to facilitate clinic staff referring patients to smoking treatment via a 1-click referral system. She also discussed how clinic staffs’ attitudes influenced implementation of the modified EHR referral system. For example, clinic staff tended not to read prompts, but to summarize in their own words, often emphasizing what they felt was most appealing or relevant for their patients. Referral rates to the study in clinics with EHR modifications were strong compared clinics using fax referral to quitlines.
Schlam presented data from a large study (N=1154) evaluating the percentage of primary care patients who smoked who continued in chronic-care smoking treatment once they relapsed following an initial quit attempt. Sixty-three percent of participants relapsed. Of those, 80 percent agreed to engage in relapse recovery treatment, and 74 percent of the patients who relapsed actually followed through and engaged in such treatment. Chronic care treatment is complicated but feasible.
An Update to the Basics: Current Approaches for Measuring and Understanding Key Individual Differences and Cessation Outcomes. Dr. Megan Piper, presenter. To improve the value of treatment research findings—as well as the reach of smoking cessation treatment and our ability to tailor treatment effectively, it’s critical to have a shared understanding of the importance and measurement of individual characteristics and a clear definition of cessation success. The SRNT Treatment Research Network sponsored a pre-conference workshop to address these key issues including: gender and sexual orientation (Dr. Andrea Weinberger), race and socio-economic status (Dr. Monica Webb-Hooper), psychiatric comorbidity (Dr. Marc Steinberg), measurement of abstinence (Drs. Megan Piper and Anne Joseph), and bioverification of abstinence (Dr. Neal Benowitz).
1. Dr. Nayoung Kim, Comparative Effects of Combination Nicotine Replacement Therapy or Varenicline Versus Patch Monotherapy on Candidate Mediators of Early Abstinence. Poster. Conclusions: Varenicline improved pre-quit craving and smoking expectancies, whereas combination nicotine-replacement therapy (C-NRT) produced positive effects on post-quit craving, expectancies, and affect. Craving and smoking expectancies affected by pharmacotherapy treatments strongly predicted abstinence in early cessation. Although varenicline and C-NRT did not yield higher abstinence rates four weeks postquit than did patch alone in this sample, indirect effects of both varenicline and CNRT on abstinence through enhanced suppression of craving and positive smoking expectancies treatments were significant.
2. Dr. Bruce Christiansen, A Pilot Study Addressing Postpartum Smoking Relapse Among Low Income Women. Poster. Conclusion: Abstinence rates doubled among intervention participants, suggesting a clinically meaningful difference may be confirmed if replicated in larger studies. Forty-seven percent of those enrolled did not complete the six-month follow-up visit (ie, the scheduled end of treatment), reflecting the difficulties of reaching and treating this population. It is important to understand the causes of the significant attrition rate in this study so that steps can be taken to increase treatment retention.
3. Dr. Bruce Christiansen, Eighteen Years of Helping Low Income Pregnant Women Quit Smoking. Poster. Conclusion: While highly successful for 18 years, the First Breath program had to evolve to address: 1. Changes in funding in the broader context of providing prenatal services to low income women. 2. High postpartum relapse. 3. Expansion of services to family members. 4. A desire to increase its reach.
4. Dr. Nayoung Kim, Predictors of Adherence to Nicotine Replacement Therapy In Recommended Usual Care and Enhanced Treatment in Primary Care Settings. Poster. Conclusions: Nicotine dependence, environmental challenges, and motivation intensity at baseline are important predictors of daily patch and mean lozenge adherence. Smokers high in nicotine dependence, quitting motivation, quitting confidence, and awareness of smoking cue exposure and reactivity are more adherent to medication, perhaps as a way to mitigate smoking risks. Negative medication beliefs and sleep disturbance are associated with lower medication adherence. Important predictors of medication adherence vary by time, medication, and treatment condition. Notably, multiple dimensions of nicotine dependence emerge as predictors of greater medication adherence across time and medication.
5. Dr. Danielle McCarthy, Evaluation of an Electronic Health Record Enabled Comprehensive Chronic Care Smoking Treatment System for Primary Care. Poster. Conclusions: Preliminary results suggested that implementing clinic-based and telephone offers of treatment in primary care can connect smokers with treatments. Roughly 16 percent of patients who smoked received a smoking-cessation intervention in clinic. Another eight percent of patients who smoked accepted smoking-cessation interventions offered by phone. Very few patients (<2%) who were not ready to set a quit day were interested in setting a reduction goal. Among patients who set a quit date, roughly 20 percent reported being abstinent for at least 4 weeks at follow-up. These results suggested that an EHR-enabled, comprehensive, chronic-care program is feasible and has promise as a way to help primary-care patients quit smoking.
6. Dr. Nayoung Kim, A Pilot Study of Closed Loop Electronic Referral to SmokefreeTXT in Adult Outpatient Settings. Poster. Conclusions: Interoperable, HIPAA-compliant, closed-loop eReferral between healthcare systems and SmokefreeTXT is feasible and compatible with workflows in health care setting. Reach varied across clinics and phases of implementation, suggesting that context and implementation approach may affect reach in important ways. The eReferral to smokefreeTXT reach was similar across age, gender, and insurance types.
7. Mark Zehner, Connection to a Tobacco Quit Line from Primary Care Clinics: EHR-Based vs. Fax-Based Referral. Poster. Conclusions: eReferral greatly increased referral rates of smokers to the Wisconsin Tobacco Quit Line versus the previous standard of care, fax-based referrals. This EHR (electronic health record) adaption reached more high-risk smokers.
8. Dr. Tanya Schlam, Which Comes First in a Quit Attempt? Temporal Relations Between Smoking and Non-Adherence to Nicotine Replacement Therapy. Poster. Schlam presented data from a large study (N = 1154) evaluating the percentage of primary care patients who smoked who continued in chronic-care smoking treatment once they relapsed following an initial quit attempt. Sixty-three percent of participants relapsed. Of those, 80 percent agreed to engage in relapse recovery treatment, and 74 percent of the patients who relapsed actually followed through and engaged in such treatment. Chronic care treatment is complicated but feasible.
9. Dr. Jessica Cook, Withdrawal Symptoms During 48-Hour Nicotine Deprivation in Smokers with PTSD, Depression, and Non-Diagnosed Controls. Poster. Conclusions: Those with PTSD and with major depressive disorder did not report an increase in symptoms during or after nicotine deprivation that is characteristic of the tobacco withdrawal syndrome. Instead, these groups reported high, sustained symptoms across the experience. These findings differ from smoking motivational models that suggest that stopping smoking greatly increases withdrawal-related distress in smokers with mental health disorders. Further research is needed to inform models of relapse for smokers with mental health disorders.