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Introduction : Smoking remains a worldwide epidemic, and despite an increase in public acceptance of the harms of tobacco use, it remains the leading cause of preventable death. It is estimated that up to 70% of all smokers express a desire to quit, but only 3-5% of them are successful. Areas covered : The goal of this review was to evaluate the current status of smoking cessation treatments and the feasibility of implementing personalized-medicine approaches to these pharmacotherapies. We evaluated the genetics associated with higher levels of nicotine addiction and follow with an analysis of the genetic variants that affect the nicotine metabolic ratio (NMR) and the FDA approved treatments for smoking cessation. We also highlighted the gaps in the process of translating current laboratory understanding into clinical practice, and the benefits of personalized treatment approaches for a successful smoking cessation strategy. Expert opinion : Evidence supports the use of tailored therapies to ensure that the most efficient treatments are utilized in an individual's smoking cessation efforts. An understanding of the genetic effects on the efficacy of individualized smoking cessation pharmacotherapies is key to smoking cessation, ideally utilizing a polygenetic risk score that considers all genetic variation.

Smoking remains one of the most preventable causes of morbidity and mortality in the United States (1). A number of factors contribute to the initiation and maintenance of smoking behavior, including psychosocial influences (2,3), neurobehavioral traits (4), and genetic susceptibility (5-7). Prevalence rates of tobacco dependence among individuals with mental health issues are strikingly high when compared to the general population, particularly among individuals with depression and anxiety disorders (8). There are well-established relationships between impulsivity, cue reactivity, and tobacco use in the literature (9). However, the interaction between these relationships remains unclear. The primary goal of this paper is to provide an overview of the existing literature across these domains and explore their interrelationship and subsequent impact on smoking initiation and tobacco dependence. Further, the clinical implications regarding the development of potential targeted smoking cessation strategies for this population are presented.

Background: This pilot study conducted a preliminary examination of whether Cognitive Bias Modification (CBM), a computerized task to retrain cognitive-approach biases towards smoking stimuli (a) changed approach bias for cigarettes, and (b) improved smoking cessation outcomes in adolescent smokers., Methods: Sixty adolescent smokers received four weeks of Cognitive Behavioral Therapy (CBT) for smoking cessation, with CBM (90% avoidance/10% approach for smoking stimuli and 10% avoidance/90% approach for neutral stimuli) or sham (50% avoidance/50% approach for smoking and neutral stimuli) training in the Netherlands (n = 42) and the United States (n = 18)., Results: While we did not observe changes in action tendencies related to CBM, adolescents with higher smoking approach biases at baseline had greater decreases in approach biases at follow-up, compared to adolescents with smoking avoidance biases, regardless of treatment condition (p = 0.01). Intent-to-treat (ITT) analyses showed that CBM, when compared with sham trended toward higher end-of-treatment, biochemically-confirmed, seven-day point prevalence abstinence, (17.2% vs. 3.2%, p = 0.071). ITT analysis also showed that regardless of treatment condition, cotinine level (p = 0.045) and average number of cigarette smoked (p ≤ 0.001) significantly decreased over the course of treatment., Conclusions: The findings from this pilot study suggests that re-training approach biases toward cigarettes shows promise for smoking cessation among adolescent smokers. Future research should utilize larger samples and increased distinction between CBM and sham conditions, and examine mechanisms underlying the CBM approach.

Background: It is important to monitor whether anti-smoking messages (if any) are noticed by the public in China and whether they have any impact on smokers’ quitting behaviours over time., Purpose: This study aimed to examine Chinese smokers' exposure to anti-smoking messages in a range of channels and to determine if exposure was associated with subsequent quit attempts., Method: A prospective cohort design was employed. Participants were 6,509 adult smokers who completed at least one of the first three waves (2006-2009) of the International Tobacco Control (ITC) China Survey sampled from six Chinese cities. The main measures were reported exposure to anti-smoking messages in a range of channels and smokers' subsequent quit attempts. Generalized Estimating Equations (GEE) modelling was used to combine respondents from all three waves while accounting for inherent within-person correlation., Results: The overall exposure levels to anti-smoking messages were low and varied between cities and from one channel to another. Television was the medium with the greatest overall exposure (over 50% in almost all the cities across all the waves). After controlling for a range of covariates, higher level of combined exposure were positively related to higher subsequent quit attempts (adjusted odds ratio=1.03, 95% CI 1.02~1.05, p <.001); among the individual channels, exposures in newspapers and on posters were significant in their own right., Conclusion: The findings suggest that anti-smoking warning messages have the potential to stimulate Chinese smokers to make quit attempts, but they also indicate that the levels and strength of warning messages in China need to be increased. China should consider adopting proven international practices, including mandating pictorial health warnings on cigarette packages, adopting prominent point-of-sale warnings, and carrying out strong and ongoing mass media campaigns.

Background: The perception of smoking risks has positive and smoking consumption has negative effects on successful smoking cessation, but no information is now available for what is the role of smoking consumption on the relationship between perception of smoking risks and successful smoking cessation., Purpose: To assess the mediation of smoking amount on the association of perception of smoking risks with successful spontaneous smoking cessation., Method: A community-based case-control study was conducted with 294 adult spontaneous successful smoking quitters who have been quitting smoking consecutively for more than 2 years as the cases, and 347 adult failed spontaneous smoking quitters who quitted but relapsed or have been quitting smoking continuously equal to or less than 2 years as the controls. The smoking amount was evaluated by pack-year that was categorized into tertiles and scored inversely. The score of perception of smoking risks was also categorized into tertiles. Propensity score as the covariate in the regression model was used to adjust the potential confounding. The total effect was decomposed into direct effect and indirect (mediating) effect by using logistic regression based on the KHB method proposed by Karlson, Holm, and Breen. The proportion of mediating effect among the total effect is calculated as the indirect effect divided by the total effect., Results: After adjusting age, profession, education, marital status, and reasons for quitting smoking by using propensity score, the small mediating effect of smoking amount on the association of perception of smoking risks with successful spontaneous smoking cessation was observed, and the mediating effect of smoking amount was 23.75% among the total effect. The dose-response analysis showed that the mediating effect of smoking amount in the groups with middle and high score of perception of smoking risks were 10.15 and 37.84% among their total effect, respectively., Conclusion: This study reveals that smoking amount has only small mediating effect among the total effect of perception of smoking risks on the successful spontaneous smoking cessation; enhancing the smokers' perception of smoking risks could promote their attempt to reduce smoking, so as to increase the probability of successful smoking cessation.

This study examined gender differences in heroin users who first received MMT. Compared with men, female heroin users were younger and more likely to be unemployed, to have family members using illicit substances, to initiate heroin use at a younger age, to begin MMT earlier after starting heroin use, to have methamphetamine use, to initiate methamphetamine use at a younger age, and to report a child-raising burden and a prior history of traumatic experiences. Men were more likely to have use of betel quid, and to initiate alcohol, nicotine and betel quid use at a younger age than women.

We conducted a double-blind pilot study involving 11 alcohol- and nicotine-dependent patients randomized to receive either bupropion or placebo. Four of six patients on bupropion and one of five patients on placebo were abstinent from smoking at the end of medication phase. Those in the bupropion group reported significantly less craving (p < .02) and less exposure to cigarette smoke over time (expired carbon monoxide; p < .01). There were no serious adverse events and no main effects of medication group on either per subject or total number of adverse events. All those who completed treatment remained abstinent from alcohol.

Objectives: Proteomic technologies based on mass spectrometry are increasingly used as a valuable tool in clinical research allowing high-throughput protein and peptide profiling to be undertaken. Whilst previous research has focussed the application of this novel technology on the study of patients with disorders compared to comparable individuals from the healthy population, this current study seeks to determine the effect of successful treatment for alcoholism on the serum protein profile obtained., Methods: Serum samples were collected from patients after initial treatment for alcohol abuse and also 6 months after treatment. The serum samples were prepared for analysis using reverse phase magnetic bead fractionation and the resulting peptides analysed by matrix assisted laser desorption ionisation time-of-flight (MALDI-ToF) mass spectrometry., Results: Whilst the majority of the peptides detected by this approach exhibited constant levels between the two time points, three peptides were elevated at the 6-month time point compared to the initial sampling., Conclusions: Whilst disorders with very clear biological causes (such as cancer) exhibit significantly different peptide profiles, psychiatric disorders such as alcohol addiction which are multifactorial show less obvious changes. Despite this the two groups of samples could statistically be distinguished by certain peptides expression levels.

Introduction: This review examines the postmarketing experience with varenicline, including case reports, newer clinical trials and secondary analyses of large clinical datasets., Areas Covered: Varenicline has been shown to be an effective treatment in a broad range of tobacco users with medical, behavioral and diverse demographic characteristics. Recent studies finding excellent safety and efficacy in groups of smokers with diseases including chronic obstructive pulmonary disease are particularly encouraging and call for increased use of this medication for smoking cessation. Despite case reports of serious neuropsychiatric symptoms in patients taking varenicline, including changes in behavior and mood, causality has not been established. Recent analyses of large datasets from clinical trials have not demonstrated that varenicline is associated with more depression or suicidality than other treatments for smoking cessation., Expert Opinion: Now that additional clinical trials in specific populations and observational studies on treatment-seeking smokers outside of clinical trials have been published, we can be confident that varenicline remains the most efficacious monotherapy for smoking cessation and that its side-effect profile remains good. The risk-to-benefit ratio of receiving varenicline to quit smoking must include the increased chances of quitting smoking and avoiding the sizeable risks of smoked-caused disease and death that remain if tobacco addiction is not properly treated.

Background: Measuring and improving the quality of treatment for patients with substance use disorders are enduring challenges., Methods: This article describes how the Veterans Affairs health care system is using incentivized performance measures to promote more effective delivery of interventions for nicotine, illegal drug, and alcohol disorders., Results: The monitoring and incentive system has increased the delivery of evidence-based services, including screening for alcohol use disorders., Conclusions: Further work remains to be done to strengthen the connection between process-based measures and longer-term patient outcomes.

The primary aim was to examine the effect of an eight day residential treatment for nicotine dependence on perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking. Whether these variables predicted six months post treatment abstinence following residential treatment was also examined. Participants included 170 adult cigarette smokers. Perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking were assessed on the first and last day of treatment. In addition, six month continuous tobacco abstinence was evaluated. Residential treatment was found to produce significant (p < 0.001) treatment changes in all psychosocial factors except one aspect of decisional balance (i.e., cons of smoking). Psychosocial factors did not predict six month tobacco abstinence. Only age (p = 0.014) and history of mental illness (p = 0.012) were found to predict six month continuous abstinence following residential treatment. This study provides new information about how residential treatment impacts psychosocial factors considered to be important predictors of tobacco abstinence in outpatient settings.

Background: Smoking behavior among couples is often similar., Purpose: The aim of the study was to examine the relationship between the partner's smoking status and the intention to stop smoking of the index person., Method: Cross-sectional data of 1,044 patients in a random sample of 34 general medical practices in northeastern Germany were analyzed., Results: Among smokers with a non-smoking partner (SNP), more intended to quit smoking in the next six months (37.0% vs. 31.4%), compared to smokers with a smoking partner (SSP). Also, more SNP intended to quit in the next four weeks (4.7% vs. 2.7%) compared to SSP. SNP were more active in the use of self-change strategies than SSP., Conclusion: The data confirm that the partner's smoking status is related to the intention to quit smoking. Interventions should address the different needs of both smokers with a smoking partner and those with a non-smoking partner.

Background: Fundamental to a stage-based model of health behavior change is the assumption that there is non-linearity (or discontinuity) in the relationship between predictors and outcomes across stage boundaries. There is, however, little evidence to suggest the stages of the transtheoretical model (TTM) meet this assumption., Purpose: The aim of this study was to extend previous work on discontinuity in prediction to the TTM stage boundary between precontemplation and contemplation, and to test the homogeneity of the contemplation stage of change., Method: Repeated measures design with telephone surveys conducted two weeks apart. Participants were 708 randomly selected smokers, aged 18-40 years, in the precontemplation and contemplation stages of change., Results: An initial test of the stage boundary between precontemplation and contemplation revealed greater predictive power of a multivariate model in the precontemplation stage. Some evidence of discontinuity in prediction was found within the contemplation stage, between those "open to the possibility" of quitting and those "actually thinking about it." The discontinuity at the TTM boundary was reduced following the exclusion of precontemplators not interested in quitting and when those thinking about quitting within contemplation were also excluded., Conclusion: The stage boundary between precontemplation and contemplation was not strongly supported, and there was weak evidence of a discontinuity within contemplation. The findings question the utility of the current operationalization of the TTM stage boundary.

Purpose: To evaluate the attitudes, knowledge, and beliefs of future physicians regarding smoking cessation and tobacco-related issues and the development of these attributes during the course of medical education., Methods: In a cross-sectional survey, questionnaires were completed by 298 first- and fourth-year medical students at three medical schools from 2003 through 2004. The primary outcomes were knowledge of the health effects of tobacco and smoking cessation strategies, attitudes toward smoking cessation, and anticipated clinical behavior with respect to addressing smoking behavior and cessation with future patients., Results: Fourth-year medical students had knowledge scores that were 13% higher than first-year students for smoking-caused morbidity and mortality and understanding the physician's /role in smoking cessation. The average proportion of correct responses for specific knowledge of smoking cessation was only 64% and did not differ significantly between fourth- and first-year medical students. Three-quarters of fourth-year students felt they needed further training in counseling patients to stop smoking., Conclusion: In this study, medical students had not received adequate education to provide effective and appropriate smoking cessation counseling to their patients. In general, this indicates a need for medical schools to place greater emphasis on developing the knowledge-base and skills required for future physicians to effectively guide their nicotine-dependent patients to stop smoking.

Persons with serious mental illness (SMI) are faced with substantial challenges to their health. This population is two to three times more likely to smoke cigarettes than persons who do not suffer from mental illness. In particular, young adults are at high risk for vulnerability to both SMI and cigarette smoking. Although there are proven methods for smoking cessation, both pharmacologic and non-pharmacologic interventions show limited usefulness for SMI who smoke. Alternative health care options as well as support groups and physical exercise are discussed as methods that may be useful in smoking cessation. Finally, integration of smoking cessation programming into existing mental health treatment services may offer the greatest opportunity for client success.

The use of spit tobacco (ST) products is a serious public health problem in the United States. Use of ST is associated with increased risk of oral cancer, gastrointestinal neoplasms, and other deleterious effects. The prevalence of ST use among adolescents is high in many areas, especially in predominantly rural states (e.g., South Dakota, Montana). Community-wide efforts aimed at prevention and cessation of ST use among young people are needed. A total of 4089 clinicians and educators were surveyed in 1998 regarding their personal ST use and several other characteristics associated with ST prevention and cessation counseling. Educators reported significantly higher rates of ST use than did clinicians. The most prevalent barriers to ST counseling among clinicians were perceptions of patient resistance to referral to ST cessation programs and the lack of community services that effectively treat ST use. Lack of training was a major barrier to ST counseling among all educator subgroups. Although knowledge of the health effects of ST was fairly high among all subgroups, more than 10% of dentists and dental hygienists failed to report that ST use causes gum disease. Most clinicians believed that they should demonstrate leadership in efforts aimed at ST control; however, only 64% of dentists believed that repeated counseling attempts were necessary with patients who continued to use ST. Compared with clinicians, educators generally felt less obligated to provide ST counseling. Eighty percent of physicians reported counseling activities, but fewer than half of the dental professionals did. More than 75% of Drug Abuse Resistance Education (DARE) officers reported having delivered ST counseling, whereas only 4% of volunteer leaders did. Fewer than 50% of educators believed that the ST program they taught was effective. Training of various professionals in ST interventions may benefit from emphasizing different issues (reduction of personal ST use, knowledge, commitment, etc.). Our findings have implications for community-based efforts aimed at controlling ST use among young people.

Introduction: The prevalence and treatment outcome of smokeless tobacco (ST) use among hospitalized addiction patients is unclear., Methods: Using initially a retrospective and then a prospective study design, data were collected about patients who described "other tobacco use." The data examined included demographics, medical disorders, psychiatric conditions, nicotine treatment and outcome., Results: The data from the two samples were consistent. All subjects were Caucasian males, mean age 38.5 years, with daily ST use for at least one year. Most had alcohol dependence. The prevalence rate was 3% retrospectively and 7% prospectively. Interventions included nicotine gum and patches. All subjects abstained from ST use during hospitalization but follow-up data were limited., Conclusion: These observations are consistent with reports of ST use being more common in males in the general population and its association with alcohol dependence. Further research is needed into effective long-term treatment for ST use among addiction or psychiatric patients.

Most persons attending drug treatment smoke cigarettes. They will eventually experience predictable, but devastatingly high, tobacco-related mortality. Recent studies indicate that many clients are ready to quit smoking and that quitting does not threaten progress made in treatment. Methadone and other opioid treatment providers are in an excellent position to address tobacco use among their clients. The present paper describes the prevalence of smoking among methadone clients, reviews promising interventions, and describes how programs can implement a systematic approach to smoking cessation that includes creating a cue system for identifying smokers, providing brief on-site intervention, and arranging follow-up or more intensive treatment.

This paper sets out to identify why research is important in realizing the potential a harm-reduction framework has for informing policy and practice in relation to all psychoactive drugs. In doing so it includes examples of research about alcohol and tobacco, since legitimizing the harm-reduction approach requires strengthening the research foundation across both licit and illicit drugs. There are some practical as well as ethical and theoretical complexities in conducting research in this area, some of which are novel or exaggerated using harm-reduction principles. Potential impediments to research are identified. Articulation of these complexities might help to facilitate research which can help to determine the validity of harm reduction. The notion of the researchers "duty of care" might offer a way of deciding among competing accountabilities, but needs further articulation to be useful. [Translations are provided in the International Abstracts Section of this issue.]

Objectives: This study examined the efficacy of naltrexone, a long-acting opiate antagonist, as a smoking cessation aid in a double-blind placebo-controlled randomized trial. It was hypothesized that naltrexone would result in higher quit rates at the end of treatment and six months later., Methods: Subjects were 68 smokers aged 18 to 65 who smoked at least 20 cigarettes daily and wished to stop smoking. They took naltrexone or placebo daily for four weeks and were seen weekly for individual smoking cessation therapy., Results: A statistical trend towards a higher overall cessation rate (cotinine < 15 ng/mL) at end-of-treatment was observed among subjects treated with naltrexone than placebo (46.7% vs. 26.3%, respectively, odds ratio = 2.5, p < .10); however, this difference was attenuated at six months (27% vs. 15%, respectively, odds ratio = 1.9, p = ns). Stratified analysis indicated the usefulness of naltrexone primarily for female smokers and those with a history of major depression. These effects remained six months later., Conclusion: These results provide, at best, mild promise for naltrexone as a smoking cessation drug and provide another instance of a differential response to nicotine dependence treatment according to gender and depression history.

Cocaine abusers (N=43) from an outpatient drug rehabilitation program were interviewed regarding the relationship of cessation of cocaine use to cigarette smoking. Patients reported significant reductions in cigarette consumption after cessation of cocaine use (37.3+/-26.4 cigarettes per day when using cocaine vs. 18.1+/-7.0 cigarettes per day after cessation of cocaine use; P < .0001, paired t test, t=4.79 with 42 degrees of freedom). Reduction of cigarette smoking after cessation of cocaine use was reported primarily by heavy smokers. However, patients with longer clinic enrollments reported more increases and fewer reductions in the number of cigarettes smoked per day after cessation of cocaine use. Comparison of average craving scores from the most recent period of cocaine use (1 month to several years before the interview), at clinic enrollment (usually shortly after the most recent period of cocaine use), and during the 24 hours before the interview showed that patients experienced markedly decreased craving for cocaine, in contrast to only slightly decreased craving for cigarettes.