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Prior research suggests that flavors can influence the pharmacological effects of nicotine. We used commercially available JUUL pods to examine whether preferred menthol versus tobacco flavor increased the addictive potential of nicotine per se. This study recruited 15 regular JUUL e-cigarette users to complete a 2 × 2 factorial crossover trial using an entirely remote video format. Participants completed a sampling baseline session to identify preferred JUUL flavor (menthol vs. tobacco) followed by four counterbalanced experimental sessions separated by ≥ 48 hr: (a) low-nicotine dose (3% JUUL)/nonpreferred flavor; (b) low dose/preferred flavor; (c) high-nicotine dose (5% JUUL)/nonpreferred flavor; and (d) high dose/preferred flavor. In each experimental session, participants completed a puffing procedure followed by subjective ratings of e-cigarette liking and wanting (ELW), urges, and reinforcement using a JUUL pod purchase task. There was a dose-by-flavor interaction for average ELW (

Introduction Misperceptions about nicotine’s contribution to smoking-related health harms could complicate efforts to reduce the public health burden of smoking. Study goals were to describe nicotine knowledge among adults who smoke and investigate whether misperceiving nicotine as a source of health harm was associated with beneficial health behaviors, or lower uptake of using less harmful sources of nicotine to support smoking cessation attempts. Method This study used longitudinal data from 9140 adults who participated in four waves of the Population Assessment of Tobacco and Health Study and were current smokers during the first wave. Logistic regressions estimated odds ratios for correct responses across six aspects of nicotine knowledge assessed in Wave 4. Longitudinal models estimated associations between misperceptions and cigarette consumption, and odds of making a quit attempt; self-reported cessation; e-cigarette use; and use of NRT or e-cigarettes to support quit attempts. Results Participants who were non-White, older, and had lower educational attainment or income tended to be least knowledgeable about nicotine. Misperceiving nicotine as harmful to health was associated with increased odds of quit attempts (AOR: 1.12, 95% CI: 1.03, 1.23), lower odds of cessation success (AOR: 0.84, 95% CI: 0.73, 0.98) and e-cigarette use (AOR: 0.79, 95% CI: 0.72, 0.86), and lower odds of using NRT (AOR: 0.84, 95% CI: 0.71, 0.99) or e-cigarettes to support quit attempts (AOR: 0.59, 95% CI: 0.49, 0.71). Conclusion Harm reduction efforts may be impeded by misperceptions about nicotine. Further work should evaluate the effects of correcting such misperceptions through public education. Implications This study provides longitudinal evidence that among adult smokers, misperceiving nicotine as a primary cause of smoking-related diseases may be associated with reduced cessation success and lower likelihood of using less harmful nicotine products. These misperceptions may therefore impede efforts to encourage smokers ready to quit to use evidence-based cessation support such as nicotine replacement during quit attempts and limit the success of policies designed to shift smokers to less harmful sources of nicotine. Further work should evaluate the longitudinal effects of correcting nicotine misperceptions through public education targeted toward adults who smoke.

Introduction As the FDA works to determine whether a nicotine reduction policy would benefit public health, one key question is whether to mandate an immediate or gradual reduction in nicotine levels in cigarettes. The aim of this study was to determine whether the effects of gradual versus immediate nicotine reduction on cigarettes per day (CPD), total nicotine equivalents, and subjective responses differed in younger adults versus older adults. Methods Using data from a recent randomized trial conducted in the United States (N = 1250) that switched smokers over a 20-week period to very low nicotine content (VLNC) cigarettes either immediately, gradually (via monthly reductions in nicotine content), or not at all (control condition, normal nicotine content research cigarette), we analyzed the moderating effect of age (age 18–24 or 25+). Results For both age groups, CPD in the immediate condition was significantly lower relative to gradual condition (estimated mean difference of 6.3 CPD in young adults, 5.2 CPD in older adults; p’s < .05). Younger and older adults in the immediate and gradual reduction conditions had lower total nicotine equivalents at Week 20 (all p’s < .05) than those in the control condition; age group did not moderate this effect. Positive subjective responses to cigarettes were lower among young adults relative to older adults in the immediate condition. Conclusions These results indicate that an immediate reduction in nicotine would result in beneficial effects in both young and older adults. Young adults show less positive subjective effects of smoking following switching to VLNC cigarettes relative to older adults. Implications As researchers work to understand how a potential reduced-nicotine product standard for cigarettes may affect public health, one question is whether nicotine should be reduced immediately or gradually. This study demonstrates that both young and older adults who were switched immediately to the lowest content of nicotine smoked fewer CPD and had lower nicotine intake than those in the gradual condition. Furthermore, young adults appear to show lower positive subjective effects following switching to VLNC cigarettes relative to older adults. This is consistent with previous work demonstrating that young people appear to show lower abuse liability for VLNC cigarettes.

Background: Lowering nicotine in cigarettes may reduce smoking prevalences; however, it is not known whether an immediate or gradual reduction in nicotine is the optimal approach for all population groups. Objectives: We examined whether the optimal approach to nicotine reduction depended on the education, gender, or race of people who smoke and whether the optimal approach differentially benefited people who smoke based on their education, gender, or race. Methods: Secondary analysis was conducted on a randomized clinical trial (N = 1250) comparing (1) immediate reduction from 15.5 to 0.4 mg of nicotine per gram of tobacco (mg/g);(2) gradual reduction to 0.4 mg/g;(3) control group with normal nicotine cigarettes(15.5 mg/g). Outcomes included cigarettes per day(CPD), carbon monoxide(CO), total nicotine equivalents(TNE), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides(NNAL), phenanthrene tetraol(PheT), N-Acetyl-S-(2-cyanoethyl)-L-cysteine(CEMA). Data were analyzed as area under the curve(AUC). Results: Results were presented by education (High school [HS] or less n = 505, more than HS n = 745), gender (males n = 701, females n = 549), and race (Black participants n = 373,White participants n = 758). Regardless of education, gender, and race, CPD, CO, TNE, NNAL, PheT, and CEMA were lower in immediate versus gradual nicotine reduction. Comparing immediate versus the control, outcomes were lower for all subgroups; however, the magnitude of the effect for TNE varied by race. Specifically, geometric mean of the AUC of TNE in immediate versus gradual was 49 % lower in Black participants and 61 % lower in White participants (p-value = 0.047). Conclusions: Immediately reducing nicotine in cigarettes has the potential to benefit people who smoke across lower and higher educational attainment, male and female gender, and Black and White race.

Introduction Behavioral economic purchase tasks are used to estimate the reinforcing value of drugs by asking participants how much they would purchase across a range of increasing prices. We sought to validate such a task for e-cigarettes in experienced users of advanced generation, tank-style devices. Methods Dual users of cigarettes and e-cigarettes (N = 54) and exclusive e-cigarette users (N = 59) attended one session during which they completed assessments including two versions of the E-cigarette Purchase Task: one that asked how many puffs of their e-cigarette they would purchase in 24 hours at varying prices and one that asked how many mLs of e-liquid they would purchase. We correlated purchase task outcomes with other measures of e-cigarette use. We also compared the tasks across dual and exclusive users. Results Indices derived from the mLs-based task were more likely to be correlated with self-reported use rates, e-cigarette dependence, and cotinine levels than the puffs-based task. Exclusive users showed greater demand on than dual users only on the mLs version when using an F-test comparison method, while multivariate analysis of variance (MANOVA) results showed that dual users showed greater demand only on the puffs task. Conclusions Results indicate that the mLs version had greater validity than the puffs version in terms of clinical indices. Dual users may still be on a trajectory to fully switching to e-cigarettes; thus, puffs as a measure may be more intuitive, as this measure is shared by cigarettes and e-cigarettes. For exclusive users, the unit they purchase their e-liquid in may be the most relevant unit and better capture their demand for that product. Implications Behavioral economic purchase tasks have been widely used to understand nicotine use. We have developed two versions of a purchase task for e-cigarette use and compared the two versions in users of advanced generation e-cigarette devices. We found that the mLs version of the task better-reflected use patterns relative to a puffs version, which suggests that participants struggle to place monetary value on a unit of consumption (ie, puffs). Validated measures of e-cigarette reinforcement will be important as researchers and regulators determine which features of these products contribute to reinforcing efficacy.

The intrinsic functional organization of the brain changes into older adulthood. Age differences are observed at multiple spatial scales, from global reductions in modularity and segregation of distributed brain systems, to network-specific patterns of dedifferentiation. Whether dedifferentiation reflects an inevitable, global shift in brain function with age, circumscribed, experience-dependent changes, or both, is uncertain. We employed a multimethod strategy to interrogate dedifferentiation at multiple spatial scales. Multi-echo (ME) resting-state fMRI was collected in younger (n = 181) and older (n = 120) healthy adults. Cortical parcellation sensitive to individual variation was implemented for precision functional mapping of each participant while preserving group-level parcel and network labels. ME-fMRI processing and gradient mapping identified global and macroscale network differences. Multivariate functional connectivity methods tested for microscale, edge-level differences. Older adults had lower BOLD signal dimensionality, consistent with global network dedifferentiation. Gradients were largely age-invariant. Edge-level analyses revealed discrete, network-specific dedifferentiation patterns in older adults. Visual and somatosensory regions were more integrated within the functional connectome; default and frontoparietal control network regions showed greater connectivity; and the dorsal attention network was more integrated with heteromodal regions. These findings highlight the importance of multiscale, multimethod approaches to characterize the architecture of functional brain aging.

OBJECTIVE: The US Food and Drug Administration recently announced its intention to pursue a federal ban on menthol cigarettes. This qualitative study assessed reactions to a potential menthol cigarette ban among people who smoke menthol cigarettes. METHODS: As part of a laboratory study examining menthol flavor regulations, we conducted follow-up interviews with participants who smoke menthol cigarettes (N=35). We explored the following topics: (1) menthol cigarette risk perceptions; (2) knowledge, attitudes, and perceptions of menthol cigarette regulations; and (3) anticipated behavior if menthol cigarettes were banned. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. RESULTS: Many participants thought menthol cigarettes carried more health risks than non-menthol cigarettes. Some participants said regulators wanted to ban menthol cigarettes because they appeal to youth. Others thought a ban would be good for public health because fewer people, particularly youth, would smoke. Several voiced skepticism about banning only menthol cigarettes rather than all cigarettes. Most said they would use other products, including electronic cigarettes or non-menthol cigarettes, but many also thought a menthol ban could motivate them or others to quit smoking. CONCLUSIONS: Banning menthol cigarettes could lead some people who smoke menthol cigarettes to switch to potentially less harmful products, like e-cigarettes, or quit smoking, which would likely benefit public health; however, others may simply transition to non-menthol cigarettes. As regulators move forward with banning menthol cigarettes, communication campaigns explaining the public health benefits, potentially focusing on the benefits for youth, should be part of the policy implementation plan.

There has been long-standing interest in a reduced-nicotine product standard for combusted tobacco, which is within the regulatory purview of the Food and Drug Administration (FDA). In weighing whether to establish this standard, it is important to consider potential responses among people who are at elevated risk for tobacco-related health harms. In this narrative review, we summarize studies of very low nicotine content (VLNC) cigarettes conducted between 2010 and 2021 in groups that the FDA has identified as vulnerable populations. Studies conducted to date in adults with mental health conditions, adults with opioid use disorder, socioeconomically-disadvantaged adults, and youth or young adults indicate that immediate switching to VLNC cigarettes decreases smoking, with minimal or no unintended negative consequences. Few studies have investigated the effects of VLNC cigarettes in racial or ethnic minorities, people who smoke menthol cigarettes, and pregnant women, but initial findings suggest that responses of these individuals are similar to responses observed in other vulnerable populations. We are not aware of studies that have investigated VLNC cigarettes in military/veteran populations, sexual or gender minority individuals, or people living in underserved rural environments. Future research directions include understanding how to promote cessation in the context of a reduced-nicotine standard, and how to correct VLNC misperceptions in vulnerable populations. Nevertheless, the evidence to date indicates that a reduced-nicotine standard is likely to have the same beneficial effects on smoking reductions as it does in less vulnerable populations, which should provide some confidence in pursuing this regulatory approach.

Aim To gain an understanding of the impact of COVID-19 on the daily life, healthcare needs, mental wellbeing and outlook of patients with Interstitial Lung Disease (ILD) and their caregivers. Methods ILD patients and caregivers were invited to participate in a quantitative survey. Respondents could self-select to then participate in in-depth structured telephone interviews. Survey data was compared to Department of Health COVID-19 public opinion tracker findings for the comparable time period. Results There were 170 survey respones (111 patients and 59 caregivers) and 14 in-depth interview participants. 32% (n=36) of patients and 42% (n=25) of caregivers expressed extreme worry regarding COVID-19 on a 1-10 scale. 83% (n=92) of patients expressed concern about safe hospital access, 33% (n=37) had received a telephone consultation with their clinician, 43% (n=48) reported test delays, 47% (n=52) were exercising less, 23% (n=26) reported worse sleep and 15% (n=17) reported being financially worse off. Carers reported that sleep was worse for 58% (n=34), 42% (n=25) reported being worse off financially, and 40% (n=24) reported a worse diet. Worry (66%, n=39), stress (51%, n=30), anxiety (49%, n=29) were commonly reported by carers. Discussion ILD patients and caregivers reported higher levels of worry regarding COVID-19 compared to the general public. Alternative pathways for quality ILD patient care and interventions to reduce the burden of care on ILD caregivers are required.

Introduction The US Food and Drug Administration is considering implementing a reduced-nicotine standard for cigarettes. Given the high rate of smoking among people with serious mental illness (SMI), it is important to examine the responses of these smokers to very low nicotine content (VLNC) cigarettes. Methods This trial compared the effects of VLNC (0.4 mg nicotine/g tobacco) and normal nicotine content cigarettes (15.8 mg/g) over a 6-week period in non-treatment-seeking smokers with schizophrenia, schizoaffective disorder, or bipolar disorder (n = 58). Linear regression was used to examine the effects of cigarette condition on cigarettes per day, subjective responses, nicotine and tobacco toxicant exposure, craving, withdrawal symptoms, and psychiatric symptoms. Results At week 6, participants in the VLNC condition smoked fewer cigarettes per day, had lower breath carbon monoxide levels, lower craving scores, and rated their study cigarettes lower in satisfaction, reward, enjoyment, and craving reduction than those in the normal nicotine content condition (ps < .05). Week 6 psychiatric and extrapyramidal symptoms did not differ by condition, except for scores on a measure of parkinsonism, which were lower in the VLNC condition (p < .05). There were no differences across conditions on total nicotine exposure, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, withdrawal symptoms, or responses to abstinence. Conclusions These results suggest that a reduced-nicotine standard for cigarettes would reduce smoking among smokers with SMI. However, the lack of effect on total nicotine exposure indicates VLNC noncompliance, suggesting that smokers with SMI may respond to a reduced-nicotine standard by substituting alternative forms of nicotine. Implications Results from this trial suggest that a reduced-nicotine standard for cigarettes would reduce smoking rates and smoke exposure in smokers with SMI, without increasing psychiatric symptoms. However, noncompliance with VLNC cigarettes was observed, suggesting that these smokers might respond to a reduced-nicotine standard by substituting alternative forms of nicotine.

Introduction Minimal research exists on adolescent smokers’ perceptions of very low-nicotine-content (VLNC) cigarettes. As approximately half of adolescent smokers prefer menthol cigarettes, it is important to consider the influence of menthol preference on VLNC cigarette perceptions and to what extent menthol preference may affect VLNC smoking behavior. This study examined the effects of cigarette nicotine content and menthol preference or menthol smoking on health risk perceptions, subjective ratings, and carbon monoxide (CO) boost in adolescent smokers. Methods Across two counterbalanced sessions, adolescent smokers sampled VLNC and normal nicotine content (NNC) research cigarettes following overnight abstinence. Cigarettes were mentholated or non-mentholated consistent with participants’ usual brand. In each session, participants smoked the research cigarette and then completed the Perceived Health Risk Scale and Cigarette Evaluation Scale. Breath CO readings were obtained pre- and post-smoking. Mixed-factor ANOVA tests compared outcomes with cigarette type (VLNC vs. NNC) as the within-subjects factor and menthol preference as the between-subjects factor. Results Participants (N = 50) were M = 17.7 years old, smoked M = 8.2 cigarettes/day, and 56% typically smoked menthol cigarettes. Participants reported lower risk of developing lung cancer, other cancers, emphysema, bronchitis, and heart disease (ps ≤ .05) when smoking VLNC cigarettes relative to NNC cigarettes. Perceived risk of addiction and stroke did not differ by nicotine content. Menthol preference or menthol smoking did not moderate risk perceptions, subjective ratings, or CO boost. Conclusions Adolescents may incorrectly perceive that VLNC cigarettes are less harmful products. Health communication campaigns could help to correct VLNC misperceptions and potentially minimize unintended consequences of a nicotine reduction policy.

Behavioral economics in the addictions is the application of both economics and psychology to study multifaceted components of substance use decision-making behavior. One such component is demand: the relative value of a substance for a user (i.e., the association between drug use and cost). The degree to which a user values a substance can be measured via performance on hypothetical purchase tasks which replicate drug purchase and consumption. Demand has been evaluated across substances, including alcohol, marijuana, tobacco, and alternative tobacco products. Recent advances in the study of demand have greatly improved the assessment of drug value, including application to novel products, selection of optimal task unit, assessment of demand in naïve or potential future users, and the importance of instructional set specificity.

Background: We conducted a psychometric analysis of an adapted secondhand smoke (SHS) questionnaire by testing the three-component structure of the original scale that measures SHS exposure in home, work and social environments. Methods: The 15-item questionnaire was administered to 839 daily smokers participating in a multi-site randomized controlled trial. Following parallel analysis, we conducted a confirmatory factor analysis specifying a three-factor structure. Cronbach’s alphas and fit indices were calculated to assess internal consistency. Criterion validity was assessed by comparing the Social environments subscale to the Brief Wisconsin Inventory of Smoking Dependence Motives Social/Environmental Goads subscale. Predicative validity of the questionnaire was assessed using linear regressions and tobacco biomarkers of harm, NNAL, expired carbon monoxide and total cotinine. Results: Five items did not load onto any factor and were dropped, resulting in a 10-item questionnaire. The Cronbach’s alphas were (0.86), (0.77) and (0.67) for the Work, Social, and Home subscales, respectively. The WISDM subscale was moderately correlated with scores on the Social subscale (r = 0.57, p &lt, 0.001). The questionnaire demonstrated predictive validity of smoke exposure above individual’s own reported use as measured by cigarettes smoked per day. Conclusions: Three constructs emerged, results indicate that a shortened 10-item scale could be used in future studies.

Introduction Exclusive e-cigarette use has been shown to be associated with reduced levels of respiratory symptoms relative to smoking combustible cigarettes; this association has been less frequently studied in smokers using advanced-generation e-cigarette devices. Advanced-generation devices generate denser vapor than either early generation or pod-style devices, and engender longer inhalations; these vaping topography patterns may contribute to respiratory symptoms. Methods In a single-session, cross-sectional study of exclusive e-cigarette users (N = 59) and dual users of e-cigarettes and cigarettes (N = 54), participants completed questionnaires, including the American Thoracic Society Questionnaire (ATSQ) and were videotaped vaping their own device in the lab for 1 hour. Using a hierarchical regression method, we examined whether topography variables, level of nicotine concentration used in their e-cigarette device in the past month, e-cigarette dependence, amount of e-cigarette use in the past month, and smoking status (any smoking in the last month vs. none) predicted ATSQ score severity. Results There was a significant mean difference in ATSQ score across smoking status, with greater ATSQ scores for vapers who also smoked cigarettes (19.0, SD = 6.7) than for exclusive vapers (13.4, SD = 5.3). In the final model, of the predictors of interest, only cigarette smoking status predicted significantly greater ATSQ scores (overall F = 2.51, p = .006; R2 = .26; smoking status β = 0.39, p < .0001). Conclusions Findings suggest that differences in respiratory symptoms between dual and exclusive e-cigarette users appear to be attributable to combustible cigarette smoking, rather than more intense or frequent e-cigarette use across groups. Implications In this comparison of exclusive advanced-generation vape device users (N = 59) versus dual users of these devices and combustible cigarettes (N = 54), we set out to determine the extent to which smoking status and e-cigarette use variables predicted self-reported respiratory symptom severity. We found that dual users showed greater respiratory symptom severity (ATSQ scores) than exclusive vapers. Despite examining vaping topography and other variables, smoking status and race were the only significant predictor of respiratory symptoms. We conclude that combustible cigarette use, not individual vaping topography, likely accounts for differences in respiratory symptoms between dual users and exclusive vapers.

Methamphetamine (MA) is a highly addictive stimulant with recent upward trends in prevalence and associated public health problems. Drug demand, as assessed by hypothetical purchasing tasks, has been useful in addictions research and may help our understanding of the factors influencing MA use. However, no studies have assessed MA demand using current models of demand. The purpose of the current study was to assess demand for MA using a hypothetical drug purchasing task. Given high rates of cigarette smoking among MA users, it was of interest also to assess and compare demand for MA relative to cigarettes. Participants consisted of non-treatment-seeking volunteers with MA use disorder (N = 18), of whom 17 reported daily smoking. Results showed the exponentiated demand model provided a good fit to consumption data. Results from Bayesian generalized linear modeling demonstrated multiple positive relationships (posterior probability ≥75%) between self-reported drug use (days MA used in the past 30 days, cigarettes smoked per day) and indices of demand for each drug (Qo, Omax, Pmax, and break point). Comparing MA to cigarettes, results from Bayesian generalized linear mixed modeling revealed greater abuse liability for MA compared to cigarettes (posterior probability ≥99%) based on α and essential value. Overall, the findings of the current study support the feasibility and validity of the exponentiated demand model for assessing demand for drugs among individuals with MA use disorder. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background A trend has recently emerged of individuals using electronic nicotine delivery systems (ENDS) or similar devices to vaporize cannabis, either in the form of high-potency THC concentrates or cannabis plant material. Peer use is central to the adoption of substance use behaviors in young adulthood, but little is known about peer influence for initiating cannabis vaping. Methods A longitudinal investigation of first-year college students (N = 1313) using social network methods was conducted to determine the prevalence of vaping cannabis, differences in networks between individuals who initiate vaping cannabis, and predictors of initiation of vaping cannabis across two time points. The surveys were available for two weeks beginning in the sixth week of each semester. Results We found that 9.4% vaped in their lifetime but not since the first survey, 7.5% vaped in their lifetime and since the first survey, and 5.9% reported vaping cannabis at the second survey. Lifetime cannabis use, lifetime ENDS use, and number of peers who initiated vaping cannabis from Time 1 to Time 2 were significantly associated with increased odds of the initiation of vaping cannabis; the number of any-cannabis-using or any-ENDS-using peers was not associated with increased odds of initiating vaping cannabis. Conclusions Individuals with the greatest risk of initiation of vaping cannabis during the first year of college are those with a prior history of other cannabis use and ENDS use and who have peers in their network who initiate cannabis vaping.

Mandating a reduction in the nicotine content of cigarettes to a minimally addictive level could dramatically reduce smoking rates in the US. However, little is known about the effects of reduced nicotine content cigarettes in adolescents.Following overnight abstinence, adolescent daily smokers (ages 15-19, n = 50) reported on their craving, withdrawal, and positive and negative affect pre- and post- ad lib smoking of one cigarette containing varying nicotine content (15.8, 5.2, 1.3 and 0.4 mg/g of tobacco) in the laboratory and reported their subjective evaluations of each cigarette. Carbon monoxide (CO) boost from pre- to post-cigarette was calculated to determine if lower-nicotine cigarettes led to differential acute changes in toxicant exposure.All four nicotine cigarette types significantly reduced abstinence-induced craving, withdrawal, and negative affect (all p's .05). Mixed models evaluating the effect of nicotine content, with nicotine dependence level and gender included as covariates, revealed a significant effect of nicotine content on craving and subjective evaluations: higher nicotine content resulted in greater reductions in craving and increases in both positive and negative subjective evaluations. There were no significant effects of nicotine dose on withdrawal symptoms, negative affect, or CO boost.These results suggest that lower nicotine cigarettes might result in reduced abuse liability compared to higher nicotine content cigarettes due to reduced positive subjective effects, while still reducing withdrawal, in adolescents. These results highlight the potential feasibility of this policy approach and support continued research on how a nicotine reduction policy may affect adolescent smoking patterns.

Introduction Reducing the level of nicotine in cigarettes is a regulatory strategy that has the potential to greatly improve public health. If nicotine levels are reduced in all commercially available cigarettes, current smokers might find it easier to quit and young people might be less likely to become dependent. However, it is not yet known whether age moderates subjective or behavioral responses to low-nicotine cigarettes. Methods Recently, a large, multisite randomized clinical trial was conducted to compare the effects of cigarettes differing in nicotine content (either usual-brand or research cigarettes containing 15.8, 5.2, 2.4, 1.3, or 0.4 mg nicotine/g tobacco) across 6 weeks of exposure. In this secondary analysis, we tested whether age moderated smokers' subjective (measures of psychological reward, smoking satisfaction) and behavioral (cigarettes smoked per day, smoking topography, and nicotine exposure) responses to cigarettes varying in nicotine content after 2 and 6 weeks of use, while controlling for baseline dependence and demographic factors. Results Results indicated that younger adults (age 18-24) who smoked cigarettes with 2.4-0.4 mg/g nicotine reported significantly less smoking satisfaction and psychological reward, and smoked fewer cigarettes per day, than older adults (25+ years) after 2 weeks of use. No differences in topography were observed at either time point. After 6 weeks of use, differences had diminished on all measures. Conclusions The reduced positive effects of reduced-nicotine content cigarettes in young adults suggests that this regulatory policy may reduce smoking reinforcement in this vulnerable population. Implications As the FDA considers reducing the level of nicotine in cigarettes to make them less addictive, understanding the potential impact of this policy on young people is of crucial importance. We found that young adults had significantly lower positive subjective effects to very-low nicotine content (VLNC) cigarettes and smoked fewer VLNC cigarettes than older adults after 2 weeks of use, indicating that this policy may reduce smoking reinforcement more quickly in young adults. These data add to the growing body of evidence on the potential for this policy to positively affect public health.

This commentary summarizes emerging findings on the potential impact of a nicotine reduction policy on youth and young adults. We conclude that: (1) adolescent smokers and nonsmokers alike are likely to be less sensitive to reinforcement from very low nicotine content (VLNC) cigarettes compared with adults; (2) reducing nicotine in cigarettes to 0.4 mg/g would reduce the abuse potential of cigarettes in adolescents and young adults; (3) findings to date do not support concerns that nicotine reduction leads to compensatory smoking in young smokers; and (4) if the scope of a reduced nicotine product standard were applied to all combusted tobacco products, that would likely maximize public health benefit of this policy.

Highlights • Case of patient with posterior fixation for traumatic cervical spine fracture in previously fixated cervical spine. • History of a cervical disc replacement (CDR) with adjacent segment degeneration and fusion yielded an unusual injury pattern. • Highlights the decompressive nature of bi-pedicle fractures and a satisfactory outcome with posterior stabilisation. • Protective role of CDR in high velocity trauma has yet to be established., Introduction We report a rare case of cervical spine trauma through a cervical disc replacement and adjacent multilevel disc fusions. Cervical disc replacement (CDR) is a viable option for the surgical treatment of degenerative disc disease however long term follow up data regarding this operative technique is poor specifically relating to traumatic complications. We know of no previous reports of bilateral cervical pedicle fractures occurring adjacent to CDR and anterior cervical spine instrumentation. Presentation of case A 46 year-old with a history of C6C7 CDR and C4-6 anterior cervical decompression and fusion was an unrestrained driver involved in a road traffic accident and suffered bilateral C7 pedicle fractures and a right C6C7 facet joint fracture-subluxation without neurological deficit. Reduction and fixation via a posterior approach achieved a satisfactory alignment and the patient made an uneventful recovery. Discussion A significant force coupled with cervical fixation resulted in a bilateral pedicle fracture of the cervical spine with preserved neurological function. Conclusion The protective role of the CDR has not been previously demonstrated but may have played a role in this case. The authors believe the challenges encountered in the treatment of this patient provide valuable lessons in the management of complex cervical spine trauma in the setting of previous instrumentation.

Objectives Behavioral economic purchase tasks, which estimate demand for drugs, have been successfully developed for cigarettes and are widely used. However, a validated purchase task does not yet exist for e-cigarettes. The aim of this project was to identify the relevant units for an e-cigarette purchase task (E-CPT). Methods Focus groups (N=28 participants in 7 groups, 2-7 participants per group) consisting of current e-cigarette users were conducted. Participants discussed their daily use patterns, completed a preliminary E-CPT which asked how many puffs of their e-cigarette they would consume per day at escalating prices, and discussed the extent to which the task accurately reflected their real-world behavior. Groups were recorded and transcribed; analysis focused on statements related to daily consumption and the E-CPT. Results Participants were unlikely to quantify their daily use in terms of puffs, and perceptions about the appropriate unit for an E-CPT varied across device type. Users of first-generation devices (eg, cigalikes) reported that the relevant unit was the individual device/cartridge; however, participants who purchased nicotine liquid for their device emphasized that e-liquid volume in milliliters would better reflect their use. Conclusions Multiple versions of the E-CPT may be necessary to provide valid measures of e-cigarette demand.

Developing briefer behavioral economic measures is an important priority to ensure that these measures can be used in a variety of different contexts and to reduce participant burden. We developed and sought to validate a Brief Assessment of Cigarette Demand (BACD). A 17-item Cigarette Purchase Task (CPT) and a 3-item BACD were completed concurrently in 2 community samples of smokers (Study 1, adult smokers [n = 80] with substance use disorders; Study 2, adolescent smokers [n = 81]). Responses on the CPT and BACD were compared on the following demand indices: (a) intensity (the number of cigarettes requested at no cost), (b) Omax (the maximum expenditure on cigarettes in a 24-hr period), and (c) breakpoint (the point at which consumption is totally suppressed/no cigarettes are purchased). Correlations of demand indices with cigarettes per day and nicotine dependence were calculated. Measures of cigarette demand on the CPT and BACD were significantly correlated, albeit at very different magnitudes, for all 3 indices in the adult sample (intensity, r = .86; breakpoint, r = .23; and Omax, r = .43) and for 2 of the indices in the adolescent sample (intensity, r = .97; breakpoint, r = .33). The CPT and BACD relationships with smoking and nicotine dependence were similar for breakpoint and intensity but not for Omax. As initial findings were mixed, additional validation work is recommended to improve psychometric properties before adoption. Valid brief measures of demand could have utility for research and treatment of addictive disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OBJECTIVES: The FDA is considering the implementation of a national nicotine reduction policy for cigarettes, and such a policy may reduce the reinforcing efficacy of cigarettes and ultimately reduce tobacco dependence. However, it is not yet known how different levels of nicotine may affect the reinforcing efficacy of cigarettes in adolescents. We aimed to determine how reduced nicotine content may affect adolescents’ demand for cigarettes using the cigarette purchase task (CPT). METHODS: Adolescent daily smokers (ages 15–19, n = 50) completed a CPT for their usual brand cigarette and for each dose of SPECTRUM research cigarettes (15.8, 5.2, 1.3, 0.4 mg nicotine/g tobacco) during four laboratory sessions. We conducted repeated measures ANOVAs to evaluate the effect of nicotine dose on five demand indices derived from the CPT. RESULTS: Tests revealed significantly higher demand for usual brand than each research cigarette dose (all p’s < .01); dose did not significantly affect any measure when usual brand was excluded. CONCLUSIONS: These results demonstrate the potential utility of the CPT for comparing the reinforcing efficacy of cigarettes varying in nicotine content in adolescents, and indicate a significantly reduced reinforcing efficacy of all research cigarettes relative to usual brand.

Aims To assess the impact of a reduction in the nicotine content of cigarettes on estimated consumption of reduced nicotine cigarettes and usual brand cigarettes at a variety of hypothetical prices. Design Double-blind study with participants assigned randomly to receive cigarettes for 6 weeks that were either usual brand or an investigational cigarette with one of five nicotine contents. Setting Ten sites across the United States. Participants A total of 839 eligible adult smokers randomized from 2013 to 2014. Intervention and comparator Participants received their usual brand or an investigational cigarette with one of five nicotine contents: 15.8 (primary control), 5.2, 2.4, 1.3, or 0.4 mg/g. Measurements The Cigarette Purchase Task was completed at baseline and at the week 6 post-randomization visit. Findings Compared with normal nicotine content controls, the lowest nicotine content (0.4 mg/g) reduced the number of study cigarettes participants estimated they would smoke at a range of prices [mean reduction relative to 15.8 mg/g at a price of $4.00/pack: 9.50, 95% confidence interval (CI) = 6.81,12.19]. The lowest nicotine content also reduced the maximum amount of money allocated to study cigarettes and the price at which participants reported they would stop buying study cigarettes [median reduction relative to 15.8 mg/g, 95% CI = $8.21 (4.27,12.15) per day and $0.44 (0.17,0.71) per cigarette, respectively]. A reduction in nicotine content to the lowest level also reduced the maximum amount of money allocated to usual brand cigarettes (median reduction relative to 15.8 mg/g: $4.39 per day, 95% CI = 1.88,6.90). Conclusions In current smokers, a reduction in nicotine content may reduce cigarette consumption, reduce the reinforcement value of cigarettes and increase cessation if reduced nicotine content cigarettes were the only cigarette available for purchase.

Author(s): Tidey, Jennifer W; Pacek, Lauren R; Koopmeiners, Joseph S; Vandrey, Ryan; Nardone, Natalie; Drobes, David J; Benowitz, Neal L; Dermody, Sarah S; Lemieux, Andrine; Denlinger, Rachel L; Cassidy, Rachel; al'Absi, Mustafa; Hatsukami, Dorothy K; Donny, Eric C | Abstract: BackgroundThe FDA recently acquired regulatory authority over tobacco products, leading to renewed interest in whether reducing the nicotine content of cigarettes would reduce tobacco dependence in the United States. Given the association between depressive symptoms and cigarette smoking, it is important to consider whether smokers with elevated depressive symptoms experience unique benefits or negative consequences of nicotine reduction.MethodsIn this secondary analysis of a randomized clinical trial that examined the effects of cigarettes varying in nicotine content over a 6-week period in non-treatment-seeking smokers, we used linear regression to examine whether baseline depressive symptom severity (scores on the Center for Epidemiologic Studies Depression Scale [CES-D]) moderated the effects of reduced-nicotine content (RNC) cigarettes, relative to normal-nicotine content (NNC) cigarettes, on smoking rates, depressive symptom severity, and related subjective and physiological measures.ResultsOf the 717 participants included in this analysis, 109 (15.2%) had CES-D scores ≥ 16, indicative of possible clinical depression. Relative to NNC cigarettes, RNC cigarettes reduced smoking rates, nicotine dependence, and cigarette craving, and these effects were not significantly moderated by baseline CES-D score. A significant interaction between baseline CES-D score and cigarette condition on week 6 CES-D score was observed (p l .05); among those with CES-D scores ≥ 16 at baseline, those assigned to RNC cigarettes had lower week 6 CES-D scores than those assigned to NNC cigarettes. Among those in the lowest nicotine content conditions, biochemically confirmed compliance with the RNC cigarettes was associated with an increase in CES-D score for those with baseline CES-D scores l 16 and no change in CES-D score for those with baseline CES-D scores ≥ 16.ConclusionsThese findings provide initial evidence that a reduced-nicotine standard for cigarettes may reduce smoking, without worsening depressive symptoms, among smokers with elevated depressive symptoms.ImplicationsThis secondary analysis of a recent clinical trial examined whether depressive symptom severity moderated the effects of reduced-nicotine cigarettes on smoking and depressive symptoms. Results indicate that, regardless of baseline depressive symptoms, participants randomized to reduced-nicotine cigarettes had lower smoking rates, nicotine intake, nicotine dependence, and craving at week 6 post-randomization than those assigned to normal-nicotine cigarettes. In participants with higher baseline depressive symptoms, those assigned to reduced-nicotine cigarettes had lower week 6 depressive symptoms than those assigned to normal-nicotine cigarettes. These results suggest that a nicotine reduction policy could have beneficial effects for smokers, regardless of depressive symptom severity.

For smokers with substance use disorders (SUD), perceived barriers to quitting smoking include concerns unique to effects on sobriety as well as usual concerns. We expanded our Barriers to Quitting Smoking in Substance Abuse Treatment (BQS-SAT) scale, added importance ratings, validated it, and then used the importance scores to predict smoking treatment response in smokers with substance use disorders (SUD) undergoing smoking treatment in residential treatment programs in two studies (n = 184 and 340). Both components (General Barriers, Weight Concerns) were replicated with excellent internal consistency reliability. Construct validity was supported by significant correlations with pretreatment nicotine dependence, smoking variables, smoking self-efficacy, and expected effects of smoking. General Barriers significantly predicted 1-month smoking abstinence, frequency and heaviness, and 3-month smoking frequency; Weight Concerns predicted 1-month smoking frequency. Implications involve addressing barriers with corrective information in smoking treatment for smokers with SUD.

INTRODUCTION Reducing the nicotine content of cigarettes to a minimally addictive level has been proposed as a regulatory strategy for reducing tobacco dependence. However, smokers with schizophrenia (SS) may be prone to changing their smoking topography in efforts to compensate for the reduction in nicotine content. The aims of this study were to compare smoking topography characteristics of usual-brand and very low nicotine content (VLNC) cigarettes in SS and control smokers without psychiatric illness (CS), and to determine whether nicotine replacement reversed any changes in topography produced by VLNC cigarettes. METHODS Using a within-subjects, counter-balanced design, SS (n = 27) and CS (n = 23) smoked usual brand cigarettes, VLNC cigarettes while wearing placebo patches (VLNC + PLA), or VLNC cigarettes while wearing transdermal nicotine patches totaling 42mg (VLNC + NIC) during 5-hour ad libitum smoking sessions. Cigarettes were smoked through topography measurement devices. RESULTS Across conditions, SS smoked more puffs per session and per cigarette, had higher cigarette volumes, and had shorter inter-puff intervals than CS (Ps < .01). During VLNC cigarette sessions, puff duration increased and time between puffs decreased, but participants smoked fewer puffs, resulting in a net decrease in cigarette and total session volume (Ps < .001). There were no significant interactions between group and condition. CONCLUSIONS These findings indicate that acute use of VLNC cigarettes does not increase intensity of smoking in SS, and support the feasibility of a nicotine reduction policy. IMPLICATIONS Reducing the nicotine in cigarettes to a minimally addictive level has been proposed as a means of reducing tobacco dependence. However, smokers, particularly those with schizophrenia (SS) may alter their puffing in an attempt to extract more nicotine from VLNC cigarettes. This study compared smoking topography of usual brand versus VLNC cigarettes, combined with placebo or transdermal nicotine patches, in SS and controls. Although some changes in topography were indicative of compensatory smoking, total puffs and total cigarette volume were reduced with VLNC cigarettes, indicating that acute VLNC cigarette use does not increase smoking in SS.

Introduction Menthol cigarette smokers may switch to other combusted products like menthol little cigars and cigarillos (LCCs) or switch to non-combusted products like menthol vapes if menthol cigarettes are banned or otherwise restricted. This pilot study used a behavioral economics task to understand (a) menthol cigarette demand across a range of increasing prices in the context of available alternative products and (b) how the availability of menthol LCCs affected cigarette demand and alternative product substitution. Methods Menthol smokers completed the Experimental Tobacco Marketplace task during two sessions. Cigarettes, LCCs, smokeless tobacco, vapes, and medicinal nicotine were available from an online store. The price of menthol cigarettes increased across trials while the prices of the alternative products remained constant. Menthol LCCs were available in one session and excluded in the other. Cross-price elasticity beta estimates identified significant product substitutes. Results When menthol LCCs were available, increasing the price of menthol cigarettes led to substitution with non-menthol cigarettes (β = 0.65, 95%CI = 0.34, 0.96), menthol little cigars (β = 0.39, 95%CI = 0.08, 0.70), and menthol vapes (β = 0.26, 95%CI = 0.16, 0.35). When menthol LCCs were not available, increasing the price of menthol cigarettes led to substitution with non-menthol cigarettes (β = 0.59, 95% CI = 0.08, 1.11), non-menthol cigarillos (β = 0.62, 95%CI = 0.19, 1.04), and menthol vapes (β = 0.13, 95%CI = 0.08, 0.18). Conclusions As the price of menthol cigarettes increased, demand for menthol cigarettes decreased and demand for combusted and non-combusted products increased, indicating significant substitution for menthol cigarettes. Policies targeting menthol combusted tobacco could result in some menthol smokers switching to non-combusted products like vaping devices.

Smokers with serious mental illness (SMI) are less responsive to cessation treatments than those without SMI. In this study, we compared smokers with and without SMI on validated measures of biological and psychosocial factors associated with tobacco use. Smokers with (n = 58) and without SMI (n = 83) who were enrolled in parallel clinical trials were compared on measures of carbon monoxide (CO) exposure, nicotine exposure, tobacco-specific nitrosamine exposure, craving, smoking motives, affect, perceived stress, environmental exposure to smoke/smokers, respiratory symptoms, tobacco-related health risk perceptions, and whether they had received recent advice to quit smoking from a health care provider. Data were collected between 2013 and 2017 in Providence, Rhode Island, USA. Samples were compared using independent-sample t-tests and chi-squared tests. Smokers with SMI had higher CO, nicotine, and tobacco-specific nitrosamine exposure levels, greater cigarette dependence, higher craving, and higher scores on eight out of eleven smoking motives (p's 0.05). Smokers with SMI reported more severe respiratory symptoms but lower perceived health risks of tobacco (p's 0.05). These smokers were more likely to report having received advice to quit from a medical provider in the past 6 weeks (p 0.05). Affect, stress, and exposure to smoke/smokers did not differ across samples. Our findings advance the understanding of the elevated smoking rates of people with SMI by comparing smokers with and without SMI on validated biopsychosocial measures. There is a need for interventions that reduce craving, reduce smoking motives, and increase risk awareness among smokers with SMI.

Introduction The Reinforcer Pathology Model describes how two behavioral economic processes, increased sensitivity to immediate rewards (delay discounting) and excessive reward derived from a substance (demand), both contribute to problematic patterns of substance use. In a novel application of this model, the current cross-sectional study examined how these distinct processes relate to different facets of cigarette use in adolescents. Methods Adolescent daily cigarette smokers ages 15 to 19 (Mean age 17.7, N = 50) completed a laboratory assessment of demand using a Cigarette Purchase Task for their usual brand cigarettes and an adjusting-amount delay discounting task. Demand was conceptualized as two factors (Amplitude and Persistence) and delay discounting was calculated as Area Under the Curve (log AUC). The two factors of demand and discounting AUC were included as statistical predictors of level of cigarette dependence and average number of cigarettes smoked per day in linear regression models. Results Amplitude of demand was marginally significant predictor (p = .06) of cigarettes smoked per day whereas neither Persistence of demand nor delay discounting significantly predicted this outcome. Both Amplitude of demand and delay discounting, but not Persistence, were associated with level of cigarette dependence. The effects of amplitude of demand and delay discounting on cigarette dependence or use did not significantly interact. Conclusions Results of this study suggest that amplitude of cigarette demand may be a risk factor for both cigarette consumption and dependence, while discounting – a known risk factor for cigarette initiation – may relate specifically to level of dependence.

Introduction Contingency management (CM) is effective for promoting smoking abstinence; however, moderators and mediators of CM treatment efficacy in young adult populations are under-explored. We leveraged fine-grained data from a large randomized controlled trial: 1) to determine whether early attainment of sustained abstinence mediated the effect of treatment on abstinence; 2) to test whether heavy drinking moderated the effect of treatment on abstinence; and 3) to test a serial mediation model of the effects of drinking during early treatment on sustained smoking abstinence. Methods College student smokers (N = 110) were randomized to receive either CM treatment or noncontingent reinforcement (NR) over a 21-day treatment period. All participants received $5 for providing twice-daily breath carbon monoxide (CO) samples. In CM, additional money was provided for samples that indicated smoking reduction (Initial Phase; first 7 days), and for samples ≤ 5 ppm (Abstinence Phase; following 14 days). Results CM treatment led to greater sustained abstinence relative to NR. Longer sustained abstinence in the Initial Phase partially mediated the effect of treatment on sustained abstinence in the Abstinence Phase. Heavier pretreatment drinkers had shorter periods of sustained abstinence in the Abstinence Phase; this effect was greater in CM. A serial mediation model determined that increased drinking during the Initial Phase led to decreased sustained abstinence, which then led to decreased sustained abstinence in the Abstinence Phase. Conclusions These data provide a greater understanding of how heavy drinking and early sustained abstinence may affect success during treatment in young adults undergoing contingency management treatment for smoking.

OBJECTIVES Research that can provide a scientific foundation for the United States Food and Drug Administration (FDA) tobacco policy decisions is needed to inform tobacco regulatory policy. One factor that affects the impact of a tobacco product on public health is its intensity of use, which is determined, in part, by its abuse liability or reinforcing efficacy. Behavioral economic tasks have considerable utility for assessing the reinforcing efficacy of current and emerging tobacco products. METHODS This paper provides a narrative review of several behavioral economic laboratory tasks and identifies important applications to tobacco regulatory science. RESULTS Behavioral economic laboratory assessments, including operant self-administration, choice tasks and purchase tasks, can be used generate behavioral economic data on the effect of price and other constraints on tobacco product consumption. These tasks could provide an expedited simulation of the effects of various tobacco control policies across populations of interest to the FDA. CONCLUSIONS Tobacco regulatory research questions that can be addressed with behavioral economic tasks include assessments of the impact of product characteristics on product demand, assessments of the abuse liability of novel and potential modified risk tobacco products (MRTPs), and assessments of the impact of conventional and novel products in vulnerable populations.

© 2014 Elsevier Inc. Introduction: Both the Tobacco Control Act in the U.S. and Article 9 of the Framework Convention on Tobacco Control enable governments to directly address the addictiveness of combustible tobacco by reducing nicotine through product standards. Although nicotine may have some harmful effects, the detrimental health effects of smoked tobacco are primarily due to non-nicotine constituents. Hence, the health effects of nicotine reduction would likely be determined by changes in behavior that result in changes in smoke exposure. Methods: Herein, we review the current evidence on nicotine reduction and discuss some of the challenges in establishing the empirical basis for regulatory decisions. Results: To date, research suggests that very low nicotine content cigarettes produce a desirable set of outcomes, including reduced exposure to nicotine, reduced smoking, and reduced dependence, without significant safety concerns. However, much is still unknown, including the effects of gradual versus abrupt changes in nicotine content, effects in vulnerable populations, and impact on youth. Discussion: A coordinated effort must be made to provide the best possible scientific basis for regulatory decisions. The outcome of this effort may provide the foundation for a novel approach to tobacco control that dramatically reduces the devastating health consequences of smoked tobacco.

Nicotine increases the value of some reinforcing stimuli, and this effect may contribute to nicotine's widespread abuse. We aimed to quantify this effect using a behavioral economic analysis. Six Long- Evans rats were exposed to a modified observing response procedure. In this procedure, presses to one lever resulted either in food according to a variable-interval 15 second schedule or extinction; presses to a second, observing lever illuminated stimuli correlated with the schedule in effect on the food/extinction lever (i.e., conditioned reinforcers). The FR requirement on the observing lever increased across sessions. The number of presentations of the conditioned reinforcers was plotted as a function of FR value to generate a demand curve. Nicotine was then administered at a dose of 0.3 mg/kg. All demand curves were fitted to the exponential demand equation and a parameter reflecting reinforcer value was evaluated. Nicotine increased the value of the conditioned reinforcers as measured by this equation; nicotine also increased responding on the food/extinction lever. This analysis demonstrates that nicotine increases the value of conditioned reinforcers under certain conditions. The current procedure allows for a novel method of analyzing demand for conditioned reinforcers.

Behavior plays an important role in health promotion. Exercise, smoking cessation, medication adherence, and other healthy behavior can help prevent, or even treat, some diseases. Consequently, interventions that promote healthy behavior have become increasingly common in health care settings. Many of these interventions award incentives contingent upon preventive health-related behavior. Incentive-based interventions vary considerably along several dimensions, including who is targeted in the intervention, which behavior is targeted, and what type of incentive is used. More research on the quantitative and qualitative features of many of these variables is still needed to inform treatment. However, extensive literature on basic and applied behavior analytic research is currently available to help guide the study and practice of incentive-based treatment in health care. In this integrated review, we discuss how behavior analytic research and theory can help treatment providers design and implement incentive-based interventions that promote healthy behavior.

Introduction The Alcohol Purchase Task (APT), a behavioral economic measure of alcohol's reinforcing value (demand), has been used to predict the effects of Brief Motivational Intervention (BMI) on alcohol use outcomes. However, it is not known whether BMI may be more or less efficacious, relative to control, among those with different levels of alcohol demand prior to treatment. Methods Non college-attending young adults (N = 150) reporting past-month heavy drinking were randomized to a single in-person session of BMI or a relaxation training control (REL). The BMI included delivery of personalized feedback and focused on developing discrepancy between the young adults' goals and their current pattern of alcohol use. At baseline, participants completed assessments of alcohol use and the APT. Drinking levels were re-assessed at 6 weeks and 3 months post-intervention. Demand indices derived from the APT were examined as moderators of treatment effects on follow-up drinking after covarying for baseline alcohol use. Results Two of four APT demand indices – intensity and Omax - moderated treatment outcomes. Relative to REL, BMI led to greater reductions in total number of drinks consumed and drinks per drinking day among participants with higher baseline alcohol demand. This association was not observed among participants with lower levels of alcohol demand. Conclusions These results demonstrate that BMI may be particularly beneficial for those with a high reinforcing value of alcohol. The mechanism for this effect is unclear, and determining the process by which BMI confers increased benefit for these individuals is a fruitful area for future work.

To assess the impact of a reduction in the nicotine content of cigarettes on estimated consumption of reduced nicotine cigarettes and usual brand cigarettes at a variety of hypothetical prices.Double-blind study with participants assigned randomly to receive cigarettes for 6 weeks that were either usual brand or an investigational cigarette with one of five nicotine contents.Ten sites across the United States.A total of 839 eligible adult smokers randomized from 2013 to 2014.Participants received their usual brand or an investigational cigarette with one of five nicotine contents: 15.8 (primary control), 5.2, 2.4, 1.3, or 0.4 mg/g.The Cigarette Purchase Task was completed at baseline and at the week 6 post-randomization visit.Compared with normal nicotine content controls, the lowest nicotine content (0.4 mg/g) reduced the number of study cigarettes participants estimated they would smoke at a range of prices [mean reduction relative to 15.8 mg/g at a price of $4.00/pack: 9.50, 95% confidence interval (CI) = 6.81,12.19]. The lowest nicotine content also reduced the maximum amount of money allocated to study cigarettes and the price at which participants reported they would stop buying study cigarettes [median reduction relative to 15.8 mg/g, 95% CI = $8.21 (4.27,12.15) per day and $0.44 (0.17,0.71) per cigarette, respectively]. A reduction in nicotine content to the lowest level also reduced the maximum amount of money allocated to usual brand cigarettes (median reduction relative to 15.8 mg/g: $4.39 per day, 95% CI = 1.88,6.90).In current smokers, a reduction in nicotine content may reduce cigarette consumption, reduce the reinforcement value of cigarettes and increase cessation if reduced nicotine content cigarettes were the only cigarette available for purchase.

The exponential demand equation proposed by Hursh and Silberberg (2008) provides an estimate of the essential value of a good as a function of price. The model predicts that essential value should remain constant across changes in the magnitude of a reinforcer, but may change as a function of motivational operations. In Experiment 1, rats' demand for food across a sequence of fixed-ratio schedules was assessed during open and closed economy conditions and across one- and two-pellet per reinforcer delivery conditions. The exponential equation was fitted to the relation between fixed-ratio size and the logarithm of the absolute number of reinforcers. Estimates of the rate of change in elasticity of food, the proposed measure of essential value, were compared across conditions. Essential value was equivalent across magnitudes during the closed economy, but showed a slight decrease across magnitudes during the open economy. Experiment 2 explored the behavioral mechanisms of nicotine's effects on consumption with the results from Experiment 1 serving as a within-subject frame of reference. The same subjects were administered nicotine via subcutaneously implanted osmotic minipumps at a dose of 3 mg/kg/day and exposed to both the one- and two-pellet conditions under a closed economy. Although nicotine produced large decreases in demand, essential value was not significantly changed. The data from the present experiments provide further evidence for the adequacy of the exponential demand equation as a tool for quantifying the rate of change in elasticity of a good and for assessing behavioral mechanisms of drug action.

Objectives:To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction.Methods:Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1 = poor to 5 = excellent) were also assessed.Results:Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (allp< 0.05). Thirteen attending physicians (93%) participated in the crosssectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p≤ 0.01). Residents (n= 35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability.Conclusions:The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.

Cigarette smoking remains one of the world’s leading causes of premature death. More than 5 million smokers die every year from smoking-related disease.1 Most smokers began smoking in adolescence, with 88% of current smokers reporting that they began smoking before age 18.1 Thus, adolescence is a crucial time in the development of smoking behavior. Adolescent smokers exhibit significant withdrawal symptoms and other evidence of nicotine dependence despite a tendency for adolescents to be lighter and more intermittent smokers.2–7 In addition to dependence and withdrawal, smoking also creates physical symptoms, particularly respiratory issues such as cough and production of phlegm.8 Evidence indicates that adolescent smokers show decreased lung function as well as decreased gain in expected lung function over time, and adolescent smokers are at risk for developing chronic cough and production and expulsion of phlegm.9–13 Daily adolescent smokers are also more likely to perceive their own general health - including respiratory health - to be poorer when compared to peers who have never tried cigarettes, and to endorse more health complaints in general.14,15 Therefore, even at this early stage, the health of adolescent smokers begins to diverge from their non-smoking peers. Thus, tracking and understanding adolescents’ respiratory symptoms, and in particular their smoking-related respiratory symptoms, is an important part of characterizing the sequelae of smoking in this population. For adolescents and adult smokers, the landscape of available products is also changing rapidly. Emerging tobacco products are changing our understanding of nicotine and tobacco use. E-cigarettes, dissolvable tobacco products, and very low nicotine cigarettes all deliver nicotine in very different ways, and current smokers may shift their behavior to these products in part due to concerns over health. Adult e-cigarette users, in particular, report that they switch from traditional to electronic cigarettes in part due to respiratory issues, and that e-cigarettes result in decreased cough and breathing issues compared to traditional cigarettes.16 However, the extent to which these products may affect respiratory symptoms in adolescents is unclear. A validated measure of respiratory symptoms in adolescent smokers would allow for harmonization of data across studies tracking the health effects of these new products, and allow for comparison of symptom alleviation in both adolescents and adults. In turn, this type of research could inform policies regarding the regulation of tobacco products. One self-report instrument that has been used widely for measuring general respiratory symptoms in adults is the American Thoracic Society Questionnaire (ATSQ).17 The ATSQ is an 8-item querying coughing, wheezing, phlegm production, shortness of breath, and other symptoms. The ATSQ has been used less frequently to assess respiratory symptoms specifically as they relate to smoking; however, several relevant studies have been conducted. In young adults, smokers have been found to endorse 5 of 8 distinct symptoms on average, and ATSQ scores have been shown to decrease significantly following 2 weeks of smoking abstinence, indicating criterion validity.18,19 In adolescents, a small study of 28 smokers and 18 nonsmokers showed that ATSQ scores were higher among smokers, and that smokers endorsed specific items (morning cough, shortness of breath when walking and during exercise, and getting tired easily) at significantly higher rates than nonsmokers.10 The ATSQ also has been reported to correlate with a single-item self-report of cigarettes per day in adolescent smokers.7 To date the ATSQ has not been throughly validated in a sample of adolescent smokers, and its psychometric properties and relationship to biomarkers of smoking have not been reported. Furthermore, the relationship between the ATSQ and validated measures of smoking behavior and dependence in adolescents has not been explored. The aim of the current study was to extend the limited literature on ATSQ scores in this population by validating the ATSQ in 2 studies of adolescents. We hypothesized that respiratory symptoms, as indexed by the ATSQ, would be reported at higher rates and with greater severity among smokers compared to matched nonsmokers, and that higher ATSQ scores would be associated with higher rates of smoking (indexed by self-report and biomarkers) and dependence. The ATSQ is a comparatively short, easily self-administered questionnaire. If validated, it would provide a practical instrument for assessing baseline levels of respiratory symptoms related to smoking in adolescents, and for evaluating changes in symptoms as a result of changes in product use patterns or cessation.

INTRODUCTION Smoking can be conceptualized as an operant behavior maintained by the reinforcing effects of cigarettes. Changing the magnitude and availability of alternative reinforcers should shift behavior away from smoking. Adults' smoking behavior is sensitive to the magnitude and availability of alternative reinforcers; however, the extent to which the same is true for adolescents has not yet been shown in the laboratory. METHODS To test the sensitivity of adolescent smoking behavior to changes in the magnitude of alternative reinforcement, we gave adolescents who abstained overnight the opportunity to make 20 choices between receiving two puffs of their usual-brand cigarette or money. The magnitude of the monetary reinforcer was varied across sessions in counterbalanced order ($0.00, $0.10, and $0.50). RESULTS Results indicated that adolescents' choices for puffs decreased as a function of increasing monetary reinforcer magnitude, while money choices increased. This effect was moderated by baseline smoking level and by gender, such that heavier-smoking participants and males made more cigarette choices when the alternative monetary value was zero, and decreased their choices more steeply in response to increasing monetary value. CONCLUSIONS The current study validates a laboratory choice procedure for studying smoking in adolescents, and demonstrates that adolescent smoking behavior is sensitive to changes in the magnitude of concurrently available monetary reinforcers. The current paradigm can be adapted and applied to explore the effects of other variables that may affect cigarette choice in adolescents.

Technology-based interventions to promote health are expanding rapidly. Assessing the preliminary efficacy of these interventions can be achieved by employing single-case experiments (sometimes referred to as n-of-1 studies). Although single-case experiments are often misunderstood, they offer excellent solutions to address the challenges associated with testing new technology-based interventions. This paper provides an introduction to single-case techniques and highlights advances in developing and evaluating single-case experiments, which help ensure that treatment outcomes are reliable, replicable, and generalizable. These advances include quality control standards, heuristics to guide visual analysis of time-series data, effect size calculations, and statistical analyses. They also include experimental designs to isolate the active elements in a treatment package and to assess the mechanisms of behavior change. The paper concludes with a discussion of issues related to the generality of findings derived from single-case research and how generality can be established through replication and through analysis of behavioral mechanisms.