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Individuals with schizophrenia smoke at rates three times higher than the general population in the United States, with smoking prevalence rates of at least 60% (1, 2). International studies have also typically found increased rates of smoking among persons with schizophrenia (3). A pattern of heavy smoking (more than 20 cigarettes per day) and severe nicotine dependence (4, 5) is characteristic. Smokers with schizophrenia have increased nicotine and cotinine levels that are attributed to increased nicotine intake per cigarette (6–8). Higher blood nicotine levels are associated with greater severity of tobacco dependence and more difficulty quitting. High nicotine levels may be needed for activation of low-affinity alpha-7 nicotinic receptors, which are reduced in both number and function in schizophrenia (9, 10). Evidence for this self-medication hypothesis comes from abnormal electrophysiological measures and saccadic eye movements that are reversed or improved when nicotine is administered by smoking cigarettes or with high-dose nicotine gum or nasal spray (11–13). Despite nicotine being beneficial, tobacco is not a pharmaceutical and is associated with more than 4,000 toxins and more than 60 carcinogens. Nicotine can be delivered more safely in commercially available nicotine products, including gum, nasal spray, inhalers, and patches. Schizophrenia is associated with a 20% reduced life expectancy and increased rates of smoking-related respiratory and cardiovascular diseases compared to members of the general population (14, 15). A 10-year study of elevated risk of coronary heart disease in schizophrenia showed that the risk remained extremely high even after control was added for factors such as weight and body mass index and was attributable mainly to smoking (16). Besides health, tobacco use results in other consequences, with smokers suffering financially and socially. Smokers with schizophrenia spend almost one-third of their monthly disability income on cigarettes (17). Smoking influences community integration because smokers have less income to spend on clothing and housing. As the smoking rate decreases among the general population, there is also the stigma in being a smoker in addition to the stigma of having mental illness. This can reduce success in obtaining employment, housing, or interpersonal relationships. Studies have found that heavy smoking among individuals with schizophrenia is associated with higher levels of positive symptoms and higher antipsychotic medication doses (18, 19). Despite the magnitude of tobacco use problems, quit rates for seriously mentally ill smokers are significantly lower than in the general population (5, 20). Individuals with schizophrenia are able to quit smoking, although the success is about half that of other groups (21–23). Contributing factors likely include lower motivation to quit tobacco use, fewer lifetime quit attempts, and increased severity of nicotine dependence. Another important consideration is that access to treatment for this group is reduced. Few mental health professionals identify and treat tobacco use in their patients (24, 25). Tobacco dependence interventions provided in primary care and public health settings are often brief and may lack the intensity or specialization needed for this population to stop smoking. These services often rely on a highly motivated and organized client who is ready to quit. In 2001, the University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School and Tobacco Dependence Program both collaborated to develop specialized services for smokers with schizophrenia and other mental illnesses. These differed from traditional services in several ways: services were open ended and not limited to a set number of contacts, all patients were encouraged to use a combination approach of pharmacotherapy and counseling, and there was no requirement to set a quit date to be in treatment. An addictions psychiatrist and mental health social worker that was also a certified tobacco treatment specialist provided most services. Both individual and group counseling services were available. More than 300 smokers with schizophrenia and other serious mental illnesses have received these specialty services and achieve long-term abstinence rates as high as those without a history of mental health problems (26). We describe here the treatment of one such patient.

Summary Introduction Prior research has shown that the transdermal nicotine patch is a safe and effective aid to smoking cessation, but adherence to the directed use of the nicotine patch is often low. Few studies have examined participant-reported reasons for non-adherence to nicotine patch therapy during a quit attempt. Aims The aim of this study was to evaluate adherence to nicotine patch therapy and to identify participant-reported reasons for non-adherence. Methods Participants were 201 current daily smokers who were offered 6-weekly group treatment sessions and were asked to report nicotine patch use and barriers to use. Results Seventy-one (35.3%) participants were adherent for the first 28 days of treatment and 130 (64.7%) participants were non-adherent. Commonly reported reasons for non-adherence were forgetting to put the patch on (30%), not liking the experienced side effects (15%), resuming smoking (10%) and difficulty affording the cost of the patches (7%). Conclusions Participant- reported barriers to adherence of nicotine patch therapy can be mitigated with advice from healthcare providers. Some examples of advice to patients could include carrying an extra patch, using community resources to obtain free or reduced cost nicotine patches, reviewing the effectiveness of nicotine replacement, and explaining side effects associated with the use of the nicotine patch.

Previous studies of tobacco dependence treatment have reported very low cessation rates among smokers who relapse and return to make a subsequent formal attempt to quit. This retrospective cohort study examined 1745 patients who attended a tobacco dependence clinic between 2001 and 2005, and the characteristics and outcomes of those who relapsed and returned for repeat treatment. Patients who returned for repeat treatment showed higher markers of nicotine dependence and were more likely to have a history of treatment for mental health problems than patients who attended the clinic for only one treatment episode. Among patients who relapsed and returned for repeat treatment, the 26-week abstinence rates were similar for each consecutive quit attempt (23%, 22% and 20%). Clinicians should encourage smokers who relapse after an initial treatment episode to return for treatment, and repeat treatment should focus on addressing high nicotine dependence and potentially co-occurring mental health problems in order to improve cessation outcomes.

Objective: To examine patterns of smoking and snus use and identify individual pathways of Swedish tobacco users in order to clarify whether snus use is associated with increased or decreased smoking. Methods: Retrospective analysis of data from a cross-sectional survey completed by 6752 adult Swedes in 2001–2 focusing on identifying tobacco use history by survey items on current and prior tobacco use and smoking initiation and cessation procedures. Results: 15% of the men and 19% of the women completing the survey were daily smokers. 21% of the men and 2% of the women were daily snus users. Almost all (91%) male daily smoking began before the age of 23 years, whereas initiation of daily snus use continued throughout the age range (33% of initiation after age 22). 20% of male primary snus users started daily smoking compared to 47% of non-primary snus users. Thus, the odds of initiating daily smoking were significantly lower for men who had started using snus than for those who had not (odds ratio (OR) 0.28, 95% confidence interval (CI) 0.22 to 0.36). Among male primary smokers, 28% started secondary daily snus use and 73% did not. 88% of those secondary snus users had ceased daily smoking completely by the time of the survey as compared with 56% of those primary daily smokers who never became daily snus users (OR 5.7, 95% CI 4.9 to 8.1). Among men who made attempts to quit smoking, snus was the most commonly used cessation aid, being used by 24% on their latest quit attempt. Of those men who had used one single cessation aid 58% had used snus, as compared with 38% for all nicotine replacement therapy products together. Among men who used snus as a single aid, 66% succeeded in quitting completely, as compared with 47% of those using nicotine gum (OR 2.2, 95% CI 1.3 to 3.7) or 32% for those using the nicotine patch (OR 4.2, 95% CI 2.1 to 8.6). Women using snus as an aid were also significantly more likely to quit smoking successfully than those using nicotine patches or gum. Conclusion: Use of snus in Sweden is associated with a reduced risk of becoming a daily smoker and an increased likelihood of stopping smoking.

Smoking cessation has major health benefits for men and women of all ages. However, most smokers are addicted to nicotine and fail repeatedly in their attempts to quit. Stimulation of nicotinic receptors in the brain, particularly alpha4beta2 receptors, releases dopamine in the meso-limbic area of the brain and is reinforcing. Nicotine abstinence reduces dopamine release, and this is associated with withdrawal symptoms and craving for nicotine. Eight current pharmacotherapies--bupropion, nortriptyline, clonidine and nicotine patch, gum, inhaler, lozenge and nasal spray--are moderately effective aids to smoking cessation. Each is significantly better than placebo, but approximately 80% of patients using one of these medications return to smoking within the first year. Varenicline, a specific alpha4beta2 nicotinic receptor partial agonist, is a new pharmacotherapy that stimulates dopamine and simultaneously blocks nicotine receptors. Phase II and III trials have yielded promising results suggesting that varenicline could be an important advance in the treatment of nicotine dependence.

In the mid-1970s there were no effective pharmacological treatments for tobacco dependence. The invention of nicotine gum was a major treatment advance and also greatly helped our understanding of the nature of tobacco dependence. There are now eight effective pharmacotherapies (nicotine gum, patch, nasal spray, inhaler, lozenge/tablet, bupropion, nortriptyline and clonidine) available to aid smoking cessation. Other non-nicotine agents that show promise are under investigation, including glucose, rimonabant, selegiline and varenicline. Greater knowledge of the mechanisms of action of the effective non-nicotine agents should lead to better understanding of the nature of tobacco dependence. Future research into optimal treatments should examine long-term combination pharmacotherapy combined with improved psychosocial support that is partly designed to enhance medication compliance. In addition, there is a need for studies designed to evaluate the efficacy of pharmacotherapies in populations such as youth, pregnant smokers and smokers with co-occurring mental health problems.

New Jersey was the first state to implement a licensure standard for all residential addiction treatment programs to assess and treat tobacco dependence in the context of entirely tobacco-free facilities (including grounds). A program evaluation of the first year of the policy (2001-2002) assessed the impact on programs, clients, and staff. At 1-year follow-up, all 30 residential programs surveyed provided some tobacco dependence treatment and 50% had tobacco-free grounds. Eighty-five percent of the programs accepted the state's offer to provide free NRT, reaching more than 2,326 clients. Seventy-seven percent of all clients were smokers, and 65% of the smokers reported they wanted to stop or cut down tobacco use. Forty-one percent of the smokers reported that they did not use any tobacco during their entire residential stay. There was no increase in irregular discharges, or reduction in proportion of smokers among those entering residential treatment, compared with prior years. Licensure standards regulation can be an effective mechanism for increasing the quantity and quality of tobacco dependence treatment in residential addictions programs.

Objective: To determine whether cigarette smokers in New Jersey substituted cigars following a cigarette excise tax increase. Methods: We examined data from New Jersey's 2001 and 2002 Adult Tobacco Survey (NJATS). Adjusted odds ratios were generated for ever and current cigar use, controlling for demographics and cigarette smoking status. Results: Males, whites, ever cigarette smokers, and those with higher education reported greater ever and current cigar use in both years. The adjusted odds for cigar use among recent quitters were higher in 2002 than in 2001. Conclusions: When other tobacco products' excise taxes fail to keep pace with cigarettes, there is a real potential for product substitution. Cessation of all tobacco products is necessary for the best public health outcome.

Objective: To review the evidence on the effects of moist smokeless tobacco (snus) on smoking and ill health in Sweden. Method: Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden. Results: Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use. Conclusions: Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

This study examined the feasibility of using video presentations to inform smokers about nicotine replacement treatment (NRT). The study was part of a larger trial comparing four different NRTs. Five hundred and four smokers attended a clinic on the day they stopped smoking. They were presented with a brief video overview of the four treatments. They were then randomly allocated to a treatment and shown another brief video describing that treatment in more detail. After 1 week of NRT use, participants rated how clearly the video described how the treatments work, how to use them and their possible side effects. They also rated how their experience of the product compared to expectation in terms of helpfulness, convenience and side effects. The smokers reported overwhelmingly that the videos had accurately described the product to which they had been allocated. Video presentations can be an effective way to convey information to smokers about NRT.

Background: An international expert panel convened by the Independent Scientific Committee on Drugs developed a multi-criteria decision analysis model of the relative importance of different types of harm related to the use of nicotine-containing products. Method: The group defined 12 products and 14 harm criteria. Seven criteria represented harms to the user, and the other seven indicated harms to others. The group scored all the products on each criterion for their average harm worldwide using a scale with 100 defined as the most harmful product on a given criterion, and a score of zero defined as no harm. The group also assessed relative weights for all the criteria to indicate their relative importance. Findings: Weighted averages of the scores provided a single, overall score for each product. Cigarettes (overall weighted score of 100) emerged as the most harmful product, with small cigars in second place (overall weighted score of 64). After a substantial gap to the third-place product, pipes (scoring 21), all remaining products scored 15 points or less. Interpretation: Cigarettes are the nicotine product causing by far the most harm to users and others in the world today. Attempts to switch to non-combusted sources of nicotine should be encouraged as the harms from these products are much lower.

Nicotine replacement therapy (NRT) describes a group of products delivering nicotine that are licensed for the relief of withdrawal as an aid to smoking cessation. This paper examines areas where public health considerations suggest changes should be made to the current indications and characteristics for NRT products. It is argued that the current regulatory framework restricts access to NRT without adequately considering that the likely consequence is continued dependent use of a far more harmful and widely available version of the same drug: tobacco. The paper argues that minors, pregnant smokers and smokers with cardiovascular disease (CVD) be allowed to use NRT. NRT use for smoking reduction, to support temporary abstinence, for long-term use should also be enabled and NRT products should be made as widely available as cigarettes. This paper also recommends that regulators encourage the development of less harmful forms of nicotine delivery devices to compete with cigarettes. Although this paper is written largely with reference to the UK medicines regulatory framework, these issues also apply to many other countries.

Aim. This study aimed (a) to assess whether smoking reduces anxiety when paired with a pleasant distractor and (b) to investigate the effect of smoking a cigarette on cognitive performance in non-deprived smokers. Design. Participants were allocated randomly to four conditions in a 23 2 factorial design: 1, Smoke1 Distractor; 2, Smoke1 No Distractor; 3, No Smoke1 Distractor; 4, No Smoke1 No Distractor. Setting. University psychology department (University of Surrey, UK). Participants. Forty-e ve volunteer cigarette smokers (mean consumption5 16 cigarettes per day) allowed to smoke normally prior to the study. Intervention. Participants were either allowed to smoke a cigarette of their choice in a manner of their choosing or not allowed to smoke, either with or without a concurrent distractor (a music video). Measurements. Rapid Visual Information Processing (RVIP) performance was measured via computer before and after a 10-minute break (during which the interventions took place). Mood was measured by (a) State Anxiety Inventory (SAI) and (b) Feeling State Questionnaire (FSQ), before and after the e rst RVIP task and then immediately after the break/cigarette. Findings. The RVIP task produced a signie cant increase in both measures of anxiety (SAI and FSQ stress subscale). Smoking, when paired with a distractor, did not decrease anxiety compared with when no distractor was present. Furthermore, smoking did not decrease anxiety or increase attentional (RVIP) performance compared with not smoking. Conclusion. The e ndings of this study failed to support the idea that smoking has anxiety-reducing or attention-enhancing properties in non-abstinent smokers.

Objective. To evaluate the efe cacy of a brief smoking cessation intervention with pregnant women practicable routinely by midwives. Design. Midwives were randomized to deliver the experimental intervention or usual care. The 10‐15-minute intervention was based on brief counselling, written materials, arrangements for continuing self-help support and feedback on expired-air carbon monoxide levels. The intervention was tailored to the women’s needs: those who did not want to stop smoking received a brief motivational intervention, those who wanted to stop received an intervention designed to assist them and those that had stopped recently (recent ex-smokers) received a relapse prevention intervention. Setting. Booking interviews with pregnant women in nine hospital and community trusts. Subjects. A total of 1120 pregnant women in the third month of pregnancy (249 recent ex-smokers and 871 current smokers). Main outcome measures. Three indicators of biochemically validated abstinence were collected. Continuous abstinence for at least 3 months prior to delivery, point prevalence abstinence immediately post-delivery, and continuous abstinence from 3 months pre-delivery to 6 months post-delivery. Results. Only a small proportion of the women who would have been eligible to take part in the trial were actually recruited by 178 recruiting midwives, with lack of time being cited as the main barrier. The intervention and usual care groups differed in post-delivery point prevalence abstinence rates for recent ex-smokers (65% vs. 53%, p, 0.05, one-tailed), but not in other outcome measures. Overall, 54% of ‘recent ex-smokers’ at booking and 7% of ‘current smokers’ at booking had been abstinent for at least 3 months at the time of delivery, and 23% and 3%, respectively, were still abstinent by the time the child was 6 months old (i.e. 12 months post-intervention). Smoking status at follow-up was predicted by dependence indexed by time to e rst cigarette in the morning. Conclusions. A brief ‘one-off’ smoking cessation intervention by midwives does not seem to be a practicable or effective method of helping pregnant smokers to stop. Other options such as tailored self-help materials and telephone counselling and other specialist treatments should be examined. Current smoking cessation rates in pregnancy are very low.

Nicotine replacement therapies (NRT), in the form of nicotine patch, gum, lozenge, nasal spray and inhaler, are primarily licensed as aids to long-term smoking cessation. The evidence that they are safe and effective at increasing smokers' chances of long-term quitting is very solid (1,2). It is also clear that one important mechanism of action of NRTs is that they reduce the severity of nicotine withdrawal symptoms and cravings to smoke (3,4).

Rationale: Nicotine replacement therapy (NRT) in varying forms is becoming widely used. Clinicians, therapists and regulatory authorities are interested in the abuse liability and dependence potential of the different forms. Objectives: To compare the abuse liability and dependence potential of nicotine gum, transdermal patch, spray and inhaler. Methods: 504 male and female smokers seeking help with stopping smoking were randomly allocated to the four products. Measures were taken at the designated quit date, then 1 week, 4 weeks, 12 weeks and 15 weeks later. Smokers were advised to use the product for up to 12 weeks. Those still using the product at the 12-week visit were advised to cease use by week 14. Measures included: pleasantness and satisfaction ratings at weeks 1 and 4 (used as a marker of abuse liability); ratings of feeling dependent on NRT at weeks 1, 4, 12 and 15 (used as a marker of subjective dependence); mood and physical symptoms ratings at weeks 12 and 15 (the change being used to assess physical dependence on NRT), continued usage of NRT at week 15 (used as an marker of behavioural dependence). Results: Average ratings of pleasantness were low. The nicotine patch was rated as less unpleasant to use than all other products. There were no significant differences between the products in terms of satisfaction or subjective dependence except at week 15 when no patch users rated themselves as dependent. Continued use of NRT at week 15 was related to rate of delivery of nicotine from the products – 2% for patch, 7% for gum and inhaler, 10% for spray (P

This study compared the effect of subcutaneous nicotine injections (2 x 0.3 mg and 2 x 0.6 mg) with saline on subjective and physiological measures in 18 never-smokers and 18 smokers (24-h nicotine deprived), under conditions of rest and cognitive testing. Prior to the injections the mood of the smokers had deteriorated to a level significantly below that of the never-smokers as a result of tobacco withdrawal. Cognitive tests caused reductions in calmness and increased alertness but there was no evidence of nicotine improving mood in either group under either condition. The 0.6 mg dose worsened mood in never-smokers and caused unpleasant symptoms (e.g. dizziness and arm pain) in both groups. Compared with smokers, never-smokers experienced stronger symptoms of nicotine toxicity and a greater reduction in alertness in response to the 0.6 mg dose, suggesting chronic tolerance to some nicotine effects in smokers. Nicotine produced similar increases in heart rate and decreases in finger pulse volume in both groups. Our results imply that if nicotine has a mood enhancing effect it occurs only after tolerance has been acquired to its primary adverse effects, and that its ability to reverse the mood deterioration caused by tobacco withdrawal is susceptible to situational factors such as our experimental conditions.

Smoking cessation strategies should be geared to the target group's level of motivation to quit, and degree of tobacco addiction. Motivational interventions (e.g. media campaigns) aim to encourage more people to try to stop smoking. Treatment interventions (e.g. nicotine replacement) aim to increase the chances of a quit attempt being successful. In populations which have already been saturated by motivational interventions, the overall effect of adding further motivational interventions may be rather small, and possibly non-existent in heavy smokers. As a population's smoking prevalence declines, so the balance of interventions should shift from motivational to treatment approaches. Nicotine replacement is an effective smoking cessation aid and should form the basis for treating moderate to heavy smokers. There may be a case for the development of more specialist clinics to treat motivated but addicted smokers and train health professionals how to apply effective smoking cessation methods as part of their routine work.

The 1988 US Surgeon General's Report entitled Nicotine Addiction reviewed the mass of evidence on the role of nicotine in tobacco consumption and came to three main conclusions, shown in Box 1.

Smokers attempting to quit should benefit from persisting in cognitive and behavioral coping in order to achieve and maintain abstinence. Task persistence, which describes the act of persisting in a difficult or effortful task, is likely to be required in the face of distressing smoking cues, urges to smoke, or other nicotine withdrawal symptoms. This study examined whether task persistence (also called distress tolerance) could prospectively predict smoking cessation in a mixed sample of smokers with and without schizophrenia. Smokers with schizophrenia or schizoaffective disorder (n = 71) and nonpsychiatric smokers (n = 78) seeking treatment at state-funded tobacco dependence treatment clinics completed tests of task persistence before their target quit date, and then provided tobacco use data over the 6 months after their quit date. Findings from generalized estimating equations support the hypothesis that task persistence as measured by a mirror-tracing task predicts smoking cessation while controlling for important covariates such as psychiatric diagnosis, nicotine dependence, and confidence in ability to quit. These findings add to the literature by corroborating reports suggesting that task persistence may make important contributions to smoking cessation success, and by indicating that the contribution of task persistence to smoking cessation is similar for smokers with schizophrenia and nonpsychiatric smokers. These results suggest that efforts to target task persistence in smoking cessation counseling protocols may be warranted.

INTRODUCTION: We explored the relationship between the Fagerstrom Test for Nicotine Dependence (FTND) and smoking abstinence rates in 10 randomized, double-blind placebo-controlled Phase 2-4 varenicline studies. METHODS: Participants were adult smokers (≥10 cigarettes/day) who were motivated to quit. Efficacy end points included continuous abstinence rate (CAR) for weeks 9-24 analyzed, by baseline FTND and Heaviness of Smoking Index (HSI) scores, and treatment. Data were analyzed using logistic regression models. RESULTS: Overall, 2,763 varenicline (M [SD] FTND score: 5.6 [2.2]) and 2,229 placebo subjects (5.5 [2.1]) were included in the analysis. An increase of one unit in baseline FTND or HSI score decreased the odds of abstinence at Week 24 by 11% (odds ratio [OR] 0.89, 95% CI 0.86-0.92, p < .0001) and 18% (OR 0.82, 95% CI 0.79-0.87, p < .0001), respectively. Treatment had a significant impact on CAR 9-24: odds of abstinence were increased threefold for varenicline versus placebo (OR 3.3, 95% CI 2.8-3.8, p < .0001). There was no interaction between treatment and FTND (p = .98) or HSI score (p = .97) for CAR 9-24. The HSI score predicted abstinence outcome as effectively as the FTND score. CONCLUSION: Abstinence rates decreased with increasing dependence scores. There was no interaction between treatment and baseline FTND or HSI score, suggesting that they have no effect on the efficacy of varenicline versus placebo. These results also suggest that the HSI may be as effective at predicting smoking cessation outcome as the whole FTND questionnaire.

Adult cigarette smoking prevalence trends among African Americans (AAs) and Whites are similar. However, during the decline in youth smoking that occurred between the mid-1970s and the early 1990s, the drop in smoking rates among AA adolescents was more than double that among Whites. We examined the evidence for potential explanations for this phenomenon. On the basis of our findings, we propose that racial differences in parental attitudes, religious ties, negative perceptions and experiences of the health effects of smoking, worsening poverty, increased use of food stamps, and price sensitivity were major factors contributing to the more rapid decrease in and continued lower rates of smoking among AA youths.

A case of blood-injury phobia complicated by fainting is described. Measures of cerebral blood flow velocity (CBFV) and heart rate (HR) indicated that phobic exposure reliably precipitated a marked drop in CBFV, simultaneous with an increase in HR and onset of dizziness. It is suggested that hyperventilation was a factor exacerbating fainting in this case. Muscle tensing produced small increases in cerebral blood flow velocity but these were not of sufficient magnitude to prevent onset of dizziness. The patient improved with treatment involving graded exposure, respiratory control and muscle tensing. At seven months follow-up the patient maintained improvements in anxiety and avoidance but again became faint during exposure.

RATIONALE: Nicotine nasal spray (NNS) may be better for relieving acute cigarette cravings than other nicotine replacement and it may help smokers with schizophrenia because of its rapid onset of action. OBJECTIVES: We tested whether NNS was more effective than a nicotine patch (NP; 21 mg) in reducing cue-induced craving during a 3-day abstinence. METHODS: Twenty-five smokers with schizophrenia or schizoaffective disorder (SA) were randomized to open-label NNS or NP treatment after baseline measures of craving were assessed. NNS users were instructed to dose at a minimum of 1/hour and up to a maximum of 40/day. Averages from a 4-item visual analogue scale (need, urge, want to smoke, crave a cigarette) measured craving. RESULTS: Five subjects who smoked (4 NP, 1 NNS) were excluded, leaving 21 (11 NP, 10 NNS) for analyses. No differences were detected between groups on baseline craving. On day 3, NNS users reported significantly less craving in response to smoking cues compared to NP users (mean craving scores: NNS, 7.0; NP, 20.3; p = .014). A repeated measure ANCOVA demonstrated significantly reduced craving in the NNS group compared to the NP group from baseline to day 3 (F = 5.09; p = .037). NNS users took an average of 20 doses/day, and NNS was rated as being as easy to use as NP. CONCLUSIONS: The potential utility of NNS in smokers with schizophrenia supports the need for placebo-controlled studies.

Moist snuff has been traditionally taxed in US states using an ad-valorem tax (ie, percentage of price).1 There is a movement afoot to change the taxation of moist snuff, from an ad-valorem to a weight-based system, and appears to be primarily promoted by US Smokeless Tobacco (UST).2,3 Effective 1 August 2006, moist snuff in New Jersey, previously taxed at 30% of the wholesale price, is now taxed by weight. The key rationale for the change was to reduce youth access to these products, on the basis of the assumptions that cheaper products are more attractive to youth and market share of these cheaper (ie, …

Although the use of over the counter (OTC) nicotine replacement therapy (NRT) is effective for smoking cessation, many concerns and misunderstandings persist that may reduce the effectiveness of NRT. Clinical practice and public health experts responded to a questionnaire that explored challenges associated with promoting proper NRT use and gathered recommendations on overcoming these challenges. Two predominant themes emerged including the identification of policies and practices that hinder NRT use, and smokers' views regarding NRT use. To address these needs, a two-part consensus statement about the use of OTC NRT to quit smoking was developed. The first part of the consensus statement identifies policy issues. The second part of the consensus statement was developed for smokers to reduce misperceptions and concerns about NRT by providing information on safety and the most effective use of NRT. The statement integrates state of the art clinical practice guidelines in a patient-centered format and presents information for policy makers to effectively support quit attempts.

Tobacco use is common among children and adolescents, and about 50% who try smoking will progress to regular use and dependence. Tobacco dependence is best conceptualized as a pediatric disease that should be addressed in adolescence. This article focuses on tobacco dependence, assessment and treatment, including goals of abstinence and exposure reduction. Although more research is needed, treatment success is more likely to occur with multicomponent interventions that are tailored to the individual needs and the unique issues for this age group, including issues of parental involvement and consent for treatment, developmental issues, and patient preferences. Several school-based interventions appear promising, and many resources are available to provide education for parents, youth, and health care providers.

Telephone counselling is an effective smoking cessation intervention and over the past decade smoking cessation quitlines have rapidly proliferated across North America, Europe, Asia, and elsewhere.1–8 Despite the increase in quitlines, the published data are limited and tend to focus on call volume, demographic breakdown of callers, and/or overall abstinence rates.1,4–6 Numerous factors, including but not limited to dependence, self efficacy, and stage of change, are predictive of quit attempts and abstinence. Recent research suggests that cigarette smoking behaviours have a strong seasonal component,9–11 with higher consumption and initiation in summer months and lower consumption and higher cessation in winter months. Possible …

Background. Tobacco dependence medications are effective, and combinations may offer advantages. This study evaluates abstinence rates among smokers treated in a tobacco specialist clinic with individual and/or group counseling plus combination pharmacotherapy. Methods. 790 smokers treated at the Tobacco Dependence Clinic in New Jersey from 2001–2003 and contacted 4 weeks after quit-date were studied. Patients received medications and behavioral interventions. Abstinence over the previous 7 days was evaluated at 4 weeks and 6 months. Patients lost to 6-month follow-up were considered still smoking. Results. Overall, 36% of patients were abstinent at 6 months (20% who used no medications, 37% using one medication, 37% using 2 medications, 42% using 3 medications, and 42% using 4+ medications) (P = 0.017). 27% still used medications at 6 months, and had higher abstinence rates (65%) than those who stopped their medications (27%) (P < 0.001). Number of medications predicted abstinence at 4 weeks [adjusted odds ratios = 2.30 (95% CI; 1.27–4.18) for 1 medication, 4.78 (2.72–8.40) for 2 medications, 5.83 (2.98–11.40) for 3 medications, and 11.80 (4.10–33.95) for 4+ medications]. Increasing age, increasing level of education, longer time after waking to first cigarette, more than 7 clinical contacts, and more medications used were related to higher abstinence at 6 months. Conclusions. Smokers attending a specialist tobacco dependence treatment clinic who used more medications and for longer duration had higher abstinence rates.

It has been hypothesized that smokers with schizophrenia take in more nicotine per cigarette than smokers without this disorder. This study examines this phenomenon by comparing the serum nicotine and cotinine levels in smokers with either schizophrenia or schizoaffective disorder compared to control smokers without mental illness. Serum cotinine and nicotine levels of smokers with schizophrenia or schizoaffective disorder were 1.3 times higher than control smokers (cotinine 291 versus 227 ng/mL; p = 0.0115; nicotine 28 versus 21 ng/mL; p < 0.001) despite smoking a similar number of cigarettes per day. Similar serum 3'-hydroxycotinine (3HC) to cotinine ratios in both groups indicate that this difference was not due to differences in the rate of metabolism of nicotine or cotinine. By examining serum nicotine and 3HC/cotinine ratios in addition to cotinine, this study expands upon previous research that relied on cotinine as an indirect indicator for nicotine intake. Our data support the hypothesis that the increased serum nicotine and cotinine levels observed are attributable to an increased nicotine intake per cigarette in smokers with schizophrenia as compared to those without mental illness.

A retrospective case series of 12 smokers with schizophrenia or schizoaffective disorder who had not successfully quit smoking with previous treatments for tobacco dependence were treated with nicotine nasal spray. All but one patient (92 percent) tolerated the nasal spray well, and nine (75 percent) used it at maximal doses for prolonged periods. After treatment five patients (42 percent) were abstinent from smoking for more than 90 days, and four patients (33 percent) substantially reduced the amount that they smoked. Ten patients (83 percent) used the spray in combination with other medications, and all received psychosocial support. Nicotine nasal spray was found to be well tolerated.

The discovery that bupropion is an effective treatment for tobacco dependence has triggered a rapid increase in development of potential new non-nicotine pharmacotherapies, including bromocriptine, glucose, GTS-21, reboxetine, rimonabant, selegeline and varenicline. Successful new products will need to have excellent side-effect profiles in addition to proven efficacy. New faster delivery nicotine replacement products have the promise of addressing a broader list of indications, including treatment of nicotine withdrawal during temporary abstinence and long-term nicotine maintenance. Nicotine vaccines will need to demonstrate efficacy and also improve certain consumer acceptability characteristics (e.g., frequency of injections required) before they can become widely used and successful therapies. The best hope of improved treatment comes from combining existing and new pharmacotherapies with effective behavioural therapy.

The recent publication of the 1994 OPCS survey of smoking among secondary school children confirmed that the Health of the Nation target for children's smoking (a reduction in regular smoking from 8% in 1988 to less than 6% in 1994) has not been achieved. In 1994, 12% of English schoolchildren aged 11-15 were regular smokers (as were 12% in Scotland, 9% in Wales, and 12.5% in Northern Ireland). In 1994 the government spent around pounds sterling10 million on initiatives to prevent smoking, but received around pounds sterling8643 million in tax receipts from tobacco sales, about pounds sterling108 million of which was tax receipts from the illegal sale of cigarettes to children under 16 years old. The tobacco industry spent an estimated pounds sterling100 million on promotional activities. Improving current trends in children's smoking by the year 2000 will require decisive action by the government. The government should legislate to ban tobacco advertising and should use the pounds sterling108 million taken each year in taxes from smoking children to fund smoking cessation and prevention initiatives. One of the main Health of the Nation targets for smoking is a reduction in the prevalence of regular smoking (defined as smoking one or more cigarettes per week) among 11-15 year olds in England from 8% in 1988 to less than 6% in 1994.1 The detailed results of the 1994 Office of Population Censuses and Surveys' survey of children's smoking, published recently, confirmed that the proportion of English secondary school children smoking regularly has actually increased to 12%.2 Figure 1 shows the smoking rates for girls and boys in England from 1982 to 1994. This shows that children's smoking has remained fairly stable over the past 15 years, with 1988 having the lowest rates and 1994 one of the highest (the highest rates …