Study Highlights Tobacco Industry’s Research on Using Menthol To Manipulate Smokers

A study in Drug and Alcohol Dependence has found that beginning in the 1970s, tobacco companies added menthol to regular, nonflavored cigarettes imperceptibly, or subliminally, to alter perceived harshness, strength, mouthfeel, and after-taste. The study also found that tobacco companies began looking into using menthol as a subliminal additive as early as the mid-1950s, when filtered cigarettes, which generally have a milder tobacco taste than unfiltered cigarettes, shot up in popularity among smokers.

“The companies studied which concentrations of menthol (including levels detectable and subliminal … to smokers) increase experimentation, promote initiation and progression to regular smoking, and attract specific demographic groups,” wrote Andre Luiz Oliveira da Silva, Ph.D., of the Brazilian Health Regulatory Agency in Rio de Janeiro, and colleagues.

Studies going back to 2009 have suggested that smoking menthol cigarettes makes it harder for people to quit smoking. More than 50 countries have now placed some restrictions on the use of menthol in tobacco products, though in most instances menthol is not banned outright but rather prohibited from being used as a primary flavor.

The researchers examined reports and other materials obtained from the Truth Tobacco Industry Documents archive, a web-based repository of millions of previously secret, internal documents in the tobacco industry dated from 1955 to 2012. These documents were revealed during litigation between U.S. states and the major tobacco companies and other sources.

As early as 1957, a “motivation survey” market research report showed that research was already being conducted about the importance of converting people who smoke nonmenthol cigarettes to menthol cigarettes.

The researchers found that the tobacco companies studied menthol’s sensory effects to determine how many parts per million of menthol they could add to their tobacco without smokers detecting it. The tobacco companies also considered which menthol concentrations to use with the goal of converting people who smoked nonmenthol cigarettes to menthol cigarettes. The reports showed the companies did not identify a precise menthol concentration to convert a nonmentholated smoker, and as a result they used a continuum of menthol levels across their brands.

“There is no scientific or health justification for allowing menthol, its derivatives, and/or synthetic cooling chemicals as tobacco/nicotine product additives or flavor add-ons at any concentration,” the researchers wrote. “The industry research and product development activities described here indicate that just prohibiting menthol as a characterizing flavor is at best an incomplete regulatory approach.”

For related information, see the Psychiatric News article “FDA Bans Some Flavored E-Cigarettes but Advocates Say Policy Falls Short.”

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For Smokers With Schizophrenia, Varenicline Found Most Effective at Achieving Abstinence

Smokers with schizophrenia who received pharmacotherapeutic smoking cessation aids, especially the medication varenicline, had significantly higher abstinence rates compared with smokers with schizophrenia who received a placebo, according to a study published in Psychiatric Services.

“Despite evidence of the safety and efficacy of first-line pharmacotherapeutic cessation aids in this population, clinicians report negative attitudes toward providing smoking cessation treatment for smokers with schizophrenia, and pharmacotherapy—particularly non-nicotine pharmacotherapy—is particularly underutilized,” wrote A. Eden Evins, M.D., M.P.H., of Massachusetts General Hospital and colleagues.

Evins and colleagues analyzed data on abstinence rates and neuropsychiatric adverse events (NPSAEs) that were collected as part of the Evaluating Adverse Events in a Global Smoking Cessation Study (EAGLES). EAGLES was conducted from November 2011 to January 2015 with participants aged 18 to 75 who smoked 10 or more cigarettes a day. There were 390 participants with schizophrenia spectrum disorders (including schizophrenia and schizoaffective disorders) and 4,028 without a psychiatric illness (the control group).

Participants were randomly assigned to receive 1 mg varenicline twice daily, 150 mg buproprion sustained-release twice daily, 21 mg of a nicotine replacement therapy patch daily, or a placebo for 12 weeks. Participants set a quit date for one week after random assignment, and study visits occurred weekly for six weeks, biweekly for six weeks, and then at weeks 13, 16, 20, and 24. Participants also received 10 minutes of smoking cessation counseling at each visit.

During each study visit, smokers with schizophrenia who were assigned to varenicline had significantly higher rates of abstinence (defined as self-reported tobacco abstinence since the previous study visit) compared with the placebo group. Participants receiving buproprion and nicotine replacement therapy also had higher rates of abstinence than the participants in the placebo group, though the rates were not as high as those for the group receiving varenicline. The participants without a psychiatric disorder overall had higher rates of abstinence, with varenicline also associated with the highest rates.

Neuropsychiatric adverse events were not significantly higher for smokers with schizophrenia receiving any active treatment compared with the placebo group. The estimated rate of neuropsychiatric adverse events was 5% for participants with schizophrenia and 1% for participants without a psychiatric disorder.

“Tobacco smokers, particularly smokers with schizophrenia, need help to quit,” the authors concluded. “These data, together with strong evidence that smoking cessation does not exacerbate mental illness and strong consistent evidence for low abstinence rates among smokers with schizophrenia with behavioral treatment alone,” support greater use of smoking cessation aids for smokers with schizophrenia as a standard of care.

For related information, see the Psychiatric News article “Schizophrenia Patients Show Cognitive Improvements After Smoking Cessation.”

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Register for Webinar on 2021 Changes to Billing and Documentation for Outpatient E/M Services

Register to attend this webinar on Tuesday, November 17 at 8 p.m. ET to learn about the changes to billing and documentation for Outpatient E/M services that will take effect on January 1, 2021. The webinar will include how to select the appropriate CPT code based on medical decision making or time, a review of the necessary documentation, and a Q&A portion with APA’s CPT coding and documentation experts.

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Isolation Puts Seniors With Substance Use Disorders at Heightened Risk During COVID-19

The social distancing and stay-at-home orders of the COVID-19 pandemic may present a challenge for people with substance use disorders by triggering anxiety, depression, or the urge to take drugs or drink alcohol. For people ages 65 or older, a population already vulnerable to the mental health effects of isolation, sequestering may be disproportionately burdensome.

“As long as social distancing guidelines remain in place, older adults in recovery from substance use disorders may find themselves cut off from support if they are unable to effectively use online treatment and self-help resources,” wrote Derek D. Satre, Ph.D., of the University of California, San Francisco, and Kaiser Permanente and colleagues in an article in the American Journal of Geriatric Psychiatry.

In the article, Satre and colleagues outlined key areas of concern for mental health professionals who work with seniors and offer guidance on how to help older patients.

Alcohol. Alcohol use can impair the immune system and increase susceptibility to pneumonia and other infectious diseases. Minimizing alcohol consumption may be critical for seniors during the pandemic, the authors wrote. They encourage mental health professionals to ask about their senior patients’ drinking habits and any recent increases in drinking that may stem from causes such as social isolation, financial stressors, anxiety, depression, or thoughts of suicide. The authors noted that pharmacologic treatments for alcohol use disorders such as naltrexone and brief behavioral interventions such as motivational interviewing can be incorporated into care, including care provided through telemedicine.

Tobacco and cannabis. Satre and colleagues noted evidence that smoking tobacco raises the risk of more severe COVID-19–related symptoms and that vaping nicotine “may damage lungs in ways that make users especially vulnerable to COVID-19–related symptoms.” They wrote that patients should be encouraged to use nicotine replacement products such as patches or gum or take anti-craving medications such as bupropion. They added that patients who use cannabis should use edible forms rather than smoke or vape.

Prescription opioids and benzodiazepines. Social distancing and quarantine may interrupt care for people with opioid use disorder and decrease their access to medication treatment, they wrote. “Lack of treatment access, in combination with social isolation, increases vulnerability to relapse and overdose for older adults during the pandemic.”

Satre and colleagues noted that although there are no published data regarding changes in benzodiazepine prescription rates associated with the pandemic, previous research has shown increased use associated with “disaster situations.” They added that the American Geriatrics Society Beers Criteria strongly recommends avoiding benzodiazepine use in seniors except in specific circumstances such as alcohol withdrawal because of the risk of cognitive impairment, falls, fractures, delirium, and other serious adverse events.

“Risks to older adults can be addressed by helping to expand access to interventions and by incorporating the assistance of partners, family, and caregivers in helping older patients use healthier coping techniques to manage stress as the pandemic continues,” they concluded.

For related information, see the Psychiatric News article “SAMHSA Issues Guidance on OUD Treatment During COVID-19.”

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Join Us for APA’s Spring Highlights Meeting This Weekend

APA’s free, live virtual Spring Highlights Meeting is just days away. Join psychiatry’s foremost experts and leaders this Saturday and Sunday, April 25 and 26, for discussions about physician leadership in a time of crisis, challenges and opportunities in research, and more. Participants in the free Spring Highlights Meeting can claim up to 10 AMA PRA Category 1 Credits and 8 hours of MOC Part 2 Credit but must register to claim credit.

Secondhand Smoke May Raise Risk of Depressive Symptoms in Adolescents

Adolescents who are exposed to secondhand smoke may be more likely to develop symptoms of depression, a study in the American Journal of Preventive Medicine has found. The risk is also dose-dependent, meaning that the more secondhand smoke to which an adolescent is exposed, the higher the risk.

“Smoking has been linked with depressive symptoms in adolescents, but data on secondhand smoking and depressive symptoms in low- and middle-income countries are scarce,” wrote Louis Jacob, Ph.D., of the University of Versailles Saint-Quentin-en-Yvelines in France and colleagues. “This is an important omission as enforcement of tobacco control policy legislation is weaker in [low- and middle-income countries] compared with high-income countries.”

The researchers analyzed data from the 2003-2008 Global School-Based Student Health Survey of more than 37,000 adolescents aged 12 to 15 years who had never smoked and who lived in 22 low- or middle-income countries. To determine participants’ exposure to secondhand smoke, they were asked, “During the past seven days, on how many days have people smoked in your presence?” To determine whether participants had experienced symptoms of depression, they were asked, “During the past 12 months, did you ever feel so sad or hopeless every day for two weeks or more in a row that you stopped doing your usual activities?”

Overall, 53.6% of the participants had been exposed to secondhand smoke on at least one day in the past week, and 24.5% had experienced depressive symptoms in the past year. Nearly 29% of participants who were exposed to secondhand smoke every day over the past week had experienced depressive symptoms compared with 23% of those who were not exposed to secondhand smoke. Compared with those who were not exposed to secondhand smoke over the previous week, those who were exposed on at least three days were 48% more likely to have experienced depressive symptoms, while those who were exposed on all seven days were 63% more likely to have experienced depressive symptoms.

The researchers wrote that the increased risk of depressive symptoms in adolescents exposed to secondhand smoke may stem from increased levels of perceived stress because of physical discomfort, the association between secondhand smoke and chronic physical conditions in childhood and adolescence such as asthma, and/or the effects of nicotine on neurotransmitters and inflammation.

“If corroborated by further longitudinal studies, these findings suggest that reducing [secondhand smoke] exposure may be important not only for the prevention of physical diseases such as ischemic heart disease, lung cancer, and asthma, but also for adolescent depressive symptoms in [low- and middle-income countries],” the researchers wrote.

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Energy Drink Consumption Among Youth Associated With Tobacco, Alcohol Use

Youth who drink energy drinks (beverages that contain high levels of caffeine) may be more likely to start drinking alcohol or using tobacco, suggests a study published in the Journal of Psychopharmacology. 

“Aggressive marketing tailored toward youth through carefully crafted campaigns, including sponsorship of events that appeal to this age group (for example, snowboarding), and product placement in video games and social media has resulted in exponential growth of their sales among minors in recent years,” wrote Artur Galimov, M.D., of Keck School of Medicine of the University of Southern California and colleagues. 

The researchers collected data from a longitudinal study of 3,071 youth aged 9 to 17 in 44 German schools. Galimov and colleagues analyzed survey data on energy drink, tobacco, and alcohol use obtained from these youth at two time points about 12 months apart. As part of the study, youth were asked to rate their interest in sensation seeking (“How often do you do dangerous things to have fun?”) and substance use (“Have you ever been curious about trying cigarettes/e-cigarettes or e-hookah/hookah/alcohol?”). They were also asked to rate their amount of school stress (determined by how much they reported agreeing with such statements as “I have too much to do for school” and “I find school assignments very difficult.”)

Baseline energy drink consumption was associated with significantly higher odds of initiating any tobacco, cigarette, e-cigarette, hookah, and alcohol use. After one year, 29.2% of the 1,061 students who had ever consumed an energy drink had begun to use tobacco, and 30.1% had begun to use alcohol. Among the 2,010 students who had never consumed energy drinks, 5.6% had initiated any type of tobacco use at the one-year follow up, and 10.4% had used alcohol.

Students who drank energy drinks were also more likely to report school stress.

“Hence, the effects of [energy drinks] may become a means of coping with increasing and stressful demands in adolescents’ lives,” the authors wrote. 

“Further research is needed to understand whether these associations may be causal,” the authors concluded. 

For related information, see the American Journal of Psychiatry article “Neural Predictors of Initiating Alcohol Use During Adolescence.” 

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Depression, Substance Use Rising Among Former Cigarette Smokers

The prevalence of depression and substance use is rising among former cigarette smokers, potentially putting them at risk for relapsing to smoking, a study in the American Journal of Preventive Medicine has found. Moreover, this increase could threaten the progress that has been made at a population level in reducing cigarette use.

Keely Cheslack-Postava, Ph.D., of Columbia University, and colleagues analyzed data from the National Survey on Drug Use and Health (NSDUH) to determine trends in major depression, alcohol use, and marijuana use among more than 67,000 adult former smokers. The NSDUH is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration that asks participants about substance use, mental health, and more.

In 2016, 6.04% of former smokers had experienced a major depressive episode within the previous year, up from 4.88% in 2005. From 2002 to 2016, past-year marijuana use nearly doubled from 5.35% to 10.09%, and past-month binge alcohol drinking increased from 17.22% to 22.33%.

“What seems of potential interest here from a tobacco control perspective is that recent data suggest that depression, marijuana use, and alcohol misuse among former smokers are associated with significantly increased risk for relapse to cigarette use,” the researchers wrote.

“Addressing risk factors for smoking relapse that are increasing among former smokers may aid them in long-term abstinence and avoidance of relapse to smoking and the consequent harmful consequences of active smoking,” they continued. “Therefore, former smokers should be continually monitored for relapse to smoking as well as for behaviors that are related to smoking relapse. In addition, public health and clinical interventions can target modifiable risk factors and reduce the likelihood of relapse.”

For information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco.”

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American Heart Association Issues Recommendations on E-Cigarettes

Today, the American Heart Association (AHA) issued a new policy statement on the use and control of e-cigarettes, including some key guidelines related to the use of these devices in tobacco-cessation counseling.

The AHA noted that current empirical evidence is very limited and has not established that e-cigarettes are any more effective than other cessation tools; at best, they have been shown to work as well as nicotine patches without behavioral support. In addition, e-cigarettes suffer from an absence of long-term safety studies and a lack of proper regulation.

As such, the AHA policy does not support e-cigarettes as a primary aid in smoking cessation. It recommends clinicians should continue to use proven cessation strategies as the first line of treatment for patients.

In cases where repeated efforts with conventional treatment fail, are not well tolerated, or are rejected by a patient, however, clinicians should not discourage the use of e-cigarettes if requested by the patient.

The AHA did stress that clinicians need to remain educated so they can inform patients that though e-cigarette aerosol may be less toxic than cigarette smoke, e-cigarettes still pose potential health risks and have not been approved by the FDA as smoking-cessation devices.

"Nicotine is a dangerous and highly addictive chemical no matter what form it takes – conventional cigarettes or some other tobacco product," said AHA President Elliott Antman, M.D.

In addition to cessation guidelines, the AHA policy statement provides recommendations in other areas of e-cigarette control including clean air laws, taxation, regulation, preventing access to youth, marketing and advertising, surveillance, and defining e-cigarettes as tobacco products.

To learn about the FDA effort to correct public misperception that e-cigarettes are safe alternatives to traditional cigarettes, see the Psychiatric News article “FDA Proposes Rule to Regulate E-Cigarettes.”

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FDA Proposes New Rule to Control E-Cigarettes, Other Tobacco Products

The U.S. Food and Drug Administration yesterday proposed a rule extending the agency’s authority to regulate electronic cigarettes and other tobacco products.

“E-cigarettes” vaporize liquid nicotine for inhalation. They are controversial because they are seen by some as devices that only perpetuate nicotine addiction and by others as a useful way to wean smokers off ordinary cigarettes, much like nicotine patches or gum. E-cigarettes are also a public health concern for individuals with severe mental illness because of their high rate of nicotine use.

Besides the addictive potential of e-cigarettes, the liquid nicotine used by e-cigarettes can be toxic when ingested or absorbed through the skin. Poison control officials have raised concerns about that danger, especially for young children who pick up bottles of the liquid that adults use for refilling the e-cigarettes.

The FDA already regulates cigarettes and cigarette tobacco, as well as snuff and chewing tobacco. Along with e-cigarettes, the agency seeks to add cigars, pipe tobacco, nicotine gels, and hookah tobacco to its purview. The proposal would add age restrictions to sales of such products, add health warnings, and prohibit sales from vending machines accessible to young people.

The proposed rule, said FDA Commissioner Margaret Hamburg, M.D., in a statement, “would also help to correct a misperception by consumers that tobacco products not regulated by FDA are safe alternatives to currently regulated tobacco products.”

The FDA has opened a 75-day period for anyone who wishes to comment on the proposal.

For more in Psychiatric News about e-cigarettes, see "Electronic Cigarettes May Be Gateway to Tobacco Smoking."

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NIH, FDA Create Centers to Study Tobacco Use, Health Consequences

To address the complex health and regulatory issues raised by the use of tobacco products, the National Institutes of Health (NIH) and the Food and Drug Administration (FDA) announced today that they are partnering to spend $53 million to fund 14 centers—called Tobacco Centers of Regulatory Science—to conduct research that the agencies hope will lead to changes in tobacco regulations with the goal of protecting public health. They noted, "Despite decades of work to reduce tobacco use in the United States, it continues to be the leading cause of preventable death and disease."

Each of the centers to be funded will study a specific area that will increase understanding of the risks that come with tobacco use and tobacco addiction. In a statement announcing the new initiative, NIH Director Francis Collins, M.D., Ph.D., said, “While we’ve made tremendous strides in reducing the use of tobacco products in the U.S., smoking still accounts for one in five deaths each year, which is far too many.” The partnership, he added, will "keep us focused on reducing the burden and devastation of preventable disease caused by tobacco use."

The research will concentrate on the following seven areas relevant to tobacco manufacturing and use: reducing addiction, adverse health consequences, reducing toxicity and carcinogenicity, marketing of tobacco products, communication, economics and policies, and the diversity of tobacco products.

To read about issues concerning tobacco use and mental health, see the Psychiatric News articles "Nicotine Vaccine's Effects on Brain Evaluated" and "Many Smoking Cessation Failures Linked to Lack of Professional Help."

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