Tobacco smoking rates are decreasing in people with major depression and substance use disorder

Significant reductions in cigarette use were found among U.S. adults with major depression, substance use disorder, or both from 2006 to 2019, according to a new analysis of nationally representative survey data published today in JAMA. 

Smoking is a modifiable risk factor for cardiovascular disease and 73% of African American adults who smoke want to quit,

The study was conducted by researchers at the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration (SAMHSA).

These findings suggest that groups at higher risk of cigarette smoking can be reached by, and may have benefitted from, tobacco use prevention and cessation efforts that have led to significant declines in tobacco use in the general population. At the same time, the findings highlight remaining disparities, documenting higher smoking rates in people with psychiatric disorders than in those without.

“This study shows us that, at a population-level, reductions in tobacco use are achievable for people with psychiatric conditions, and smoking cessation should be prioritized along with treatments for substance use, depression, and other mental health disorders for people who experience them,” said Nora Volkow, M.D., director of NIDA and co-author of the study. “Therapies to help people stop smoking are safe, effective, and may even enhance the long-term success of concurrent treatments for more severe mental health symptoms in individuals with psychiatric disorders by lowering stress, anxiety, depression, and by improving overall mood and quality of life.”

Cigarette smoking, the leading preventable cause of disease, disability and death in the U.S., has been declining. Experts attribute this in part to increases in available treatments, insurance coverage of these treatments, cigarette prices, smoke-free and tobacco-free policies, mass media and educational campaigns and other evidence-based strategies to help people avoid or quit using cigarettes that have been implemented in recent decades.

Quitting cigarette smoking and tobacco use reduces the risk of cancer, heart disease, stroke and lung diseases. Studies have also found that smoking cessation in people with psychiatric disorders can help decrease anxiety, depression and stress; lower likelihood of a new-onset substance use disorder; and improve quality of life.

Past studies have documented that smoking rates remained essentially unchanged in people with substance use disorders, major depression or other psychiatric disorders. Now, analyzing data from more than 558,000 individuals aged 18 and older who participated in the 2006 to 2019 National Surveys on Drug Use and Health (NSDUH), researchers found that while people with major depression, substance use disorder or both were more likely to smoke cigarettes than people without these disorders; improvements in smoking cessation were seen among those with these psychiatric disorders during the 14-year period. The NSDUH, conducted annually by SAMHSA, provides nationally representative data on cigarette smoking, tobacco use, major depressive episode and substance (alcohol or drug) use disorders among the US civilian, non-institutionalized adult population. Among the population studied here, roughly 53% were women, 41% were aged 18 to 25 and 62% were non-Hispanic white.

After controlling for factors such as age, sex, race/ethnicity, education and family income, the researchers found that past-month smoking rates declined by 13.1% from 2006 to 2019 among adults with a past-year major depressive episode and by 8.2% from 2006 to 2019 among adults without. The difference in past-month cigarette smoking among those with versus without past-year major depressive episode significantly narrowed from 11.5% in 2006 to 6.6% in 2019.

Similarly, past-month cigarette smoking declined by 10.9% from 2006 to 2019 among adults with past-year substance use disorder and by 7.8% among adults without. For people with co-occurring substance use disorder and major depression, past-month smoking rates decreased by 13.7% during this 14-year period and by 7.6% among adults without these disorders.

“These declines tell a public health success story,” said Wilson Compton, M.D., NIDA’s Deputy Director and the senior author of the study. “However, there’s still a lot of work to be done to ensure tobacco use in patients with substance use disorder, depression, or other psychiatric conditions continue to decrease. It is crucial that healthcare providers treat all the health issues that a patient experiences, not just their depression or drug use disorder at a given point in time. To do this, smoking cessation therapies need to be integrated into existing behavioral health treatments. The result will be longer and healthier lives for all people.”

During 2006 to 2019, among adults with past-year major depressive episodes or substance use disorder, past-month cigarette smoking declined significantly across every examined age, sex, and racial and ethnic subgroup, except that among non-Hispanic American Indian or Alaska Native adults smoking rates did not decline. Given that American Indian and Alaska Native communities face the highest smoking and lowest quitting rates among racial and ethnic subgroups in the United States, this highlights the need to channel additional prevention and treatment efforts into these communities.

In future work, the researchers note the need to include data on certain populations at high risk of psychiatric disorders and cigarette smoking, such as institutionalized individuals or those experiencing homelessness without living in a shelter. More work is also needed to continue to monitor national trends in differences in tobacco use and nicotine vaping among adults with or without psychiatric conditions – including substance use disorder – during the COVID-19 pandemic.

Quitting smoking after lung cancer diagnosis may extend life without cancer recurrence

A prospective cohort study found that quitting smoking after being diagnosed with early-stage non-small cell lung cancer may slow disease progression and decrease mortality.

Given that about half of all smokers continue to smoke after a lung cancer diagnosis, these findings present an opportunity to improve overall and progression-free survival in this type of cancer.

The study is published in Annals of Internal Medicine.

More than 80% of patients with non-small cell lung cancer have a history of smoking, and about half are current smokers at the time of diagnosis.

There is limited evidence that smoking cessation may improve survival, so many patients may feel it is too late to quit once they’ve been diagnosed with lung cancer.

Researchers from the International Agency for Research on Cancer, the specialised cancer agency of the World Health Organization, in collaboration with the N.N. Blokhin National Medical Research Centre of Oncology in Russia, recruited 517 adults who currently smoked when diagnosed with early-stage non-small cell lung cancer from 2 sites in Moscow, Russia to determine whether quitting smoking after diagnosis affects the risk for disease progression and mortality.

The participants were interviewed at the start of the study to ascertain medical and lifestyle history, including tumour characteristics, and the amount of lifetime smoking, and then followed each year for an average of 7 years to record any changes in their smoking behaviour, treatments, and disease status.

Of 517 patients who were smoking when diagnosed with lung cancer, less than half quit (44.5%), and very few relapsed.

The patients who quit smoking were more likely to live longer overall (6.6 years vs. 4.8. years), live longer without lung cancer (5.7 vs. 3.9 years) and have a longer time to death from lung cancer (7.9 vs. 6 years).

According to the authors, these results show that even after being diagnosed with lung cancer, there is still significant benefit to quitting smoking.

Physicians should make their lung cancer patients aware that quitting smoking can extend life overall and extend life without cancer recurrence.

Marijuana use at historic high among college-aged adults in 2020

Marijuana use continued to rise among college students over the past five years and remained at historically high levels among same-aged peers who are not in college in 2020, according to survey results from the 2020 Monitoring the Future (MTF) panel study(link is external).

This represents the highest levels of marijuana use recorded since the 1980s. The survey also found that marijuana vaping and nicotine vaping leveled off in 2020 after sharp increases reported every year since 2017 for both college students and same-aged respondents who are not in college.

Among college students specifically, there was also a significant increase in the annual use of hallucinogens, and a substantial and significant drop in current alcohol use between 2019 and 2020.

“The COVID-19 pandemic dramatically changed the way that young people interact with one another and offers us an opportunity to examine whether drug taking behavior has shifted through these changes,” said NIDA Director Nora D. Volkow, M.D. “Moving forward, it will be critical to investigate how and when different substances are used among this young population, and the impact of these shifts over time.”

The Monitoring the Future (MTF) study has been annually tracking substance use among college students and noncollege adults ages 19-22 since 1980. Funded by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, the survey is conducted annually by scientists at the University of Michigan’s Institute for Social Research, Ann Arbor. Results are based on data from college students one to four years beyond high school graduation who are enrolled full-time in a two- or four-year college in March of the given year, compared with same-age high school graduates not enrolled full-time in college. Data for the 2020 survey were collected online from 1,550 college-aged adults between March 20, 2020 through November 30, 2020. The 2020 survey results(link is external) are now available online, and a summary of key findings is below.

Marijuana use: Annual marijuana use has continued to increase over the past five years for college students, reaching the highest level in over three-and-a-half decades in 2020. Among college students, 44% reported using marijuana in the past year in 2020, compared to 38% in 2015, representing a significant increase. For young adults not in college, annual marijuana use in 2020 remained at 43% (the same historically high level as recorded in 2018 and 2019).

In contrast, similar increases and record highs in marijuana use have not been observed among 12^th graders in recent years, with 35% of high school seniors reporting using marijuana in the past year in 2020.

In addition, daily or near daily use of marijuana has continued to rise among college students since 2015, with 8% of college students reporting using marijuana on a daily or near daily basis in 2020 compared to nearly 5% in 2015. In comparison, 13% of same-age adults not in college reported using marijuana on a daily or near daily basis in 2020, consistent with recent years.

Vaping marijuana and nicotine: The 2020 MTF survey also recorded a halt in the dramatic increases in vaping marijuana and vaping nicotine among college-aged adults observed between 2017 and 2019. During this time, the percentage of college-aged adults who reported vaping marijuana in the past 30 days more than doubled, from 5% to 14% for college students, and 8% to 17% for noncollege respondents. In 2020, these increases leveled off, with 12% of college students and 14% of noncollege respondents reporting vaping marijuana in the past 30 days. Similarly, there was a nonsignificant change for vaping nicotine in 2020, with 19% of college students and 24% of noncollege respondents reporting vaping nicotine in the past 30 days compared to 22% and 18% in 2019, and 6% and 8% in 2017, respectively.

Hallucinogen use: Past year use of hallucinogens (including LSD, psilocybin mushrooms, and other psychedelic substances) significantly increased among college students between 2019 and 2020. In 2020, nearly 9% of college students reported the use of any hallucinogens in the past year compared to 5% in 2019. Among noncollege respondents, annual use did not significantly increase in 2020, remaining consistent at around 10% compared to 8% in 2020.

Alcohol use: In 2020, college students reported significantly lower alcohol use across numerous measures compared to 2019, with 56% of students reporting alcohol use within the past 30 days (compared to 62% in 2019), and 28% reporting being drunk in the past 30 days (compared to 35% in 2019). For both measures, the trends in alcohol use had remained level between 2015 and 2019. In addition, 24% of college students reported binge drinking (consuming five or more alcoholic drinks in a row in the past two weeks) in 2020, compared to 32% in 2019.

Among noncollege respondents, trends in alcohol use across all measures were stable over the past five years, with no drop in 2020. In 2020, 49% of noncollege respondents reported alcohol use in the past 30-days, 22% reported being drunk in the past 30 days, and 24% reported binge drinking.

“Historically, college students have reported the highest levels of binge drinking compared to same-aged youth who are not enrolled in college. This is the first year where binge drinking was similar between the two groups,” said John Schulenberg, Ph.D., professor of psychology at the University of Michigan and principal investigator of the Monitoring the Future panel study. “While binge drinking has been gradually declining among college students for the past few decades, this is a new historic low, which may reflect effects of the COVID-19 pandemic in terms of reduced time with college friends.”

Other highlights from the 2020 survey results on college-age adults include:

• Cigarette smoking continued to decline over the past five years to all-time lows over the past four decades in 2020, with 4% of college students reporting having smoked in the past month and 13% of noncollege respondents reporting having smoked in the past month.
• Nonmedical use of amphetamines (including misuse of ADHD medications like Adderall®) continued to decline for college students, with a significant five-year decline in annual use to 6.5% in 2020. Though college students have typically had higher prevalence of nonmedical amphetamine use over the past decade, this gap closed in 2020, with 6% of non-college youth reporting past year use.
• Prescription opioid misuse continued to decline for college students and noncollege youth, with significant five-year declines in annual use for both groups. In 2020, 1% of college students and 3.5% of same-aged peers not in college reported non-medical use of opioids (narcotic drugs other than heroin) in the past year.

Results from the 2021 Monitoring the Future survey of substance use behaviors and related attitudes among teens in the United States are expected to publish in December 2021.

NIH study links cigarette smoking to higher stroke risk in African Americans

African Americans who smoke are nearly 2.5 times more likely to have a stroke than those who never smoked, while former smokers show a similarly lower risk as never smokers, according to a new study funded by the National Institutes of Health.

The findings from the Jackson Heart Study suggests that even after years of smoking, African Americans — who as a group are twice as likely as whites to have a stroke and die from it — could significantly reduce their risk if they kicked the habit. The study’s findings, funded by the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute for Minority Health and Health Disparities (NIMHD), both part of NIH, will appear online in the Journal of the American Heart Association(link is external).

Numerous studies have shown the link between smoking and stroke, but few have directly assessed the relationship solely in African Americans. This new study did that and also analyzed traditional risk factors for cardiovascular diseases and inflammation.

“This study provides further strong evidence of the link between cigarette smoking and stroke in African Americans,” said David Goff, M.D., Ph.D., director of the Division of Cardiovascular Sciences at NHLBI. “We know that quitting smoking is one way to lower the risk for stroke, which is particularly important for the most vulnerable populations during this pandemic.”

The study included 4,410 black men and women without a history of stroke and who were enrolled in the Jackson Heart Study, the largest study of cardiovascular disease in African Americans. Researchers classified the participants, who were 54 on average, into three groups based on their self-reported smoking history: current smokers, past smokers who smoked at least 400 cigarettes in their lifetimes, and never smokers.

The researchers further classified current smokers based on smoking intensity. One group included participants who smoked up to 19 cigarettes a day; another included those who smoked 20 or more cigarettes a day. Researchers followed participants from their initial evaluations beginning in 2000 through 2015.

At its start, the study included 781 past smokers, 546 current smokers, and 3,083 never smokers. By 2015, 5.2% of past smokers, 6.6% of those were smoking up to 19 cigarettes a day, and 7.2% of those smokers smoking more than 20 cigarettes a day had experienced a stroke, compared to 3.4% of never smokers.

After accounting for multiple risk factors for stroke, such as high blood pressure, diabetes, high “bad” cholesterol levels, and older age, researchers calculated that current smokers carried a risk for stroke that was more than double the risk for never smokers. And, the risk nearly tripled for those smoking 20 or more cigarettes each day. But past smokers showed an almost identical risk as never smokers.

“The bottom line is the more a person smokes, the greater their chance is of having a stroke,” said Adebamike A. Oshunbade, M.D., M.P.H., the lead study author and postdoctoral research fellow at the University of Mississippi Medical Center. “It’s important to communicate this risk to vulnerable populations, especially with the growing popularity of new tobacco products.”

Michael E. Hall, M.D., associate professor of medicine at the University of Mississippi Medical Center, Jackson, and corresponding study author, agreed. He noted that while smoking has been shown in major studies to raise the risk of stroke 1.5 times for the general population, “these adverse health effects seem to be magnified in African Americans.”

In their analysis, the researchers also looked more closely at the already-established link between inflammation and atherosclerosis and smoking. They measured for C-reactive protein (CRP), a marker of inflammation, and carotid intima-media thickness, or CIMT, to assess the buildup of fatty plaques in the carotid arteries that supply blood to the brain.

The researchers found that African American smokers who smoked 20 or more cigarettes a day had higher CIMT compared to never smokers. Researchers said this suggests that the buildup of plaque in the major blood vessels of the brains of African American smokers could play a role in the development of stroke.

NIH-funded study finds teens prefer mint and mango vaping flavors

A new analysis suggests that teens prefer mint and mango as their vaping flavors of choice for e-cigarettes.

E-cigarette. Photo credit: Medical News Today

 Previous research showed that teens were attracted to nicotine vaping by the candy and fruit-flavored products offered by manufacturers. Products and trends are quickly evolving, and estimates of the specific e-cigarette flavors teens use are lacking; therefore, scientists wanted to find out which flavors are now preferred by teens. The report, published in JAMA, was supported by the National Institute on Drug Abuse (NIDA), the National Cancer Institute (NCI), and the U.S. Food and Drug Administration Center for Tobacco Products. NIDA and NCI are parts of the National Institutes of Health.

The study focused on JUUL products, the most widely used brand, which is available in multiple flavors. Data were from the 2019 Monitoring the Future (MTF) study, which annually surveys eighth, 10th, and 12th grade students in U.S. schools. A randomly-selected third of MTF respondents were asked, “Which JUUL flavor do you use most often?”

The 2019 data suggests that among both 12th and 10th graders, mint and mango ranked first and second (at about 47% and 24% for seniors; 44% and 27% for 10th graders). Among eighth graders, mango was most popular at 34%, followed by mint at 29%. In all grades, fruit flavoring was ranked third, followed by “Other.” Menthol was among the least popular (less than 2.3% for eighth graders; less than 3% for 10th graders and less than 6% for seniors).

The overall 2019 Monitoring the Future vaping data released last month showed a significant increase in past month vaping of nicotine in each of the three grade levels since last year. Additional findings from the 2019 Monitoring the Future Survey, documenting the use of and attitudes about marijuana, alcohol and other drugs, will be released in December.

2.4 billion people living in countries with tobacco preventive measures

Many governments are making progress in the fight against tobacco, with 5 billion people today living in countries that have introduced smoking bans, graphic warnings on packaging and other effective tobacco control measures four times more people than a decade ago, according to WHO.

Smoking leads to disease and disability and harms nearly every organ of the body – CDC

A new WHO report also shows many countries are still not adequately implementing policies, including helping people quit tobacco, that can save lives from tobacco.

According to the WHO, the focus of the latest report is on the progress countries have made to help tobacco users quit. It is being launched today in Brazil, a country that has become the second, after Turkey, to fully implement all the MPOWER measures at the highest level of achievement.

The MPOWER measures include monitoring tobacco use and prevention policies, protecting people from tobacco smoke; offering help to quit tobacco use; warning people about the dangers of tobacco; enforcing bans on tobacco advertising, promotion and sponsorship; and raising taxes on tobacco.

Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said governments should implement cessation services as part of efforts to ensure universal health coverage for their citizens.

“Quitting tobacco is one of the best things any person can do for their own health,” said Dr Tedros. “The MPOWER package gives governments the practical tools to help people kick the habit, adding years to their life and life to their years.”

Progress is being made, with 2.4 billion people living in countries now providing comprehensive cessation services (2 billion more than in 2007). But only 23 countries are providing cessation services at the best-practice level, making it the most under-implemented MPOWER measure in terms of number of countries offering full coverage.

Tobacco cessation services include national toll-free quit lines, “mCessation” services to reach larger populations via mobile phones, counselling by primary health care providers and cost-covered nicotine replacement therapy.

Michael R. Bloomberg, WHO Global Ambassador for Noncommunicable Diseases and Injuries  and founder of Bloomberg Philanthropies, said the report shows government-led efforts to help people quit tobacco work when properly implemented.

“More countries are making tobacco control a priority and saving lives, but there’s still much more work to be done,” said Mr Bloomberg. “The WHO’s new report shines a spotlight on global efforts to help people quit using tobacco and it details some of our most important gains.”

The report, funded by Bloomberg Philanthropies, showed that while only 23 countries have implemented cessation support policies at the highest level, 116 more provide fully or partially cost-covered services in some or most health facilities, and another 32 offer services but do not cost-cover them, demonstrating a high level of public demand for support to quit.

Tobacco use has also declined proportionately in most countries, but population growth means the total number of people using tobacco has remained stubbornly high. Currently, there are an estimated 1.1 billion smokers, around 80% of whom live in low- and middle-income countries (LMICs).

Low-income, rural kids at higher risk for second- or third-hand smoke exposure

NIH-funded study suggests ways to reduce risk for infants and toddlers.

Infants and toddlers in low-income, rural areas may be at higher risk for second- and third-hand smoke than previously reported, according to a study supported by the National Institutes of Health.

Approximately 15 percent of children in the study tested positive for cotinine, a byproduct formed when the body breaks down nicotine, at levels comparable to those of adult smokers. About 63 percent of children in the study had detectable levels of cotinine, suggesting widespread exposure to smoke. The study appears in Nicotine & Tobacco Research.

“Few studies have explored the risks of very young children, especially infants, for second- or third-hand exposure to smoking,” said James A. Griffin, Ph.D., deputy chief of the Child Development and Behavior Branch at NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), which funded the research. “The current study suggests that moving frequently, having more adults in the home and spending less time in center-based daycare facilities may increase a child’s exposure to smoke or smoke residue.” 

The researchers analyzed data from the Family Life Project, a long-term study of rural poverty in North Carolina and Pennsylvania. For the study, saliva samples of 1,218 children were tested for cotinine. The samples were collected from children at age 6 months, 15 months, 2 years and 4 years. The presence of cotinine indicates that the child was exposed to second- or third-hand smoke. Second-hand smoke comes from a lit tobacco product, an electronic smoking device or the smoker. Third-hand smoke is an invisible residue from smoke that settles onto floors, furniture and clothing.

The researchers classified the children into three groups based on their cotinine levels. Fifteen percent of the children were in the high exposure group, with cotinine levels comparable to active adult smokers (12ng/mL or higher), 48 percent were in the moderate exposure group (0.46 to 12ng/mL) and 37 percent were in the low exposure group (less than or equal to 0.46ng/mL). These values are higher than those seen in data previously reported in the National Health and Nutrition Examination Survey, which found that only one-third to one-half of children’s blood samples had detectable cotinine. 

“We found that infants had higher cotinine levels compared to toddlers,” said Lisa M. Gatzke-Kopp, Ph.D., a professor at Pennsylvania State University and the lead author of the study. “Because infants often put objects into their mouths and crawl on floors, they may be more likely to ingest smoke residue or get it on their skin, compared to older children.”

The study team evaluated independent factors that may influence a child’s probability of being in one of the three exposure groups. They found that lower income, less education, frequent residential moves and fluctuations in the number of adults within the home were associated with high smoke exposure, whereas time spent at a center-based daycare was associated with lower smoke exposure.

Factors influencing cotinine levels included the following:

• When a caregiver had at least a high school degree, a child was 85 percent less likely to be in the high exposure group, compared to the other two groups.
• Each residential move increased a child’s odds of being in the high exposure group, compared to the low exposure group, by 43 percent.
• Each adult moving into or out of the home increased this risk by 11 percent.
• A child who spent time in a center-based daycare was 81 percent less likely to be in the high exposure group, compared to the low exposure group.

“Our results, if supported by future studies, can help educate parents and caregivers, as well as improve prevention programs that seek to reduce children’s smoke exposure,” said Clancy Blair, Ph.D., M.P.H., a professor at New York University’s Steinhardt School of Culture, Education and Human Development and the senior author of the study. “For instance, nonsmoking families may not be aware that nicotine can be present in their child’s environment if their home was previously occupied by a smoker or if smoking is permitted at the workplace.”

Funding for the current analysis was provided by NICHD, the National Institute on Drug Abuse, and the Environmental influences on Child Health Outcomes (ECHO) program, all part of NIH.