Investigating Tobacco Withdrawal In Opioid-Maintained Smokers And Smokers With Other Vulnerabilities

Joanna Mayers Streck, University of Vermont


While smoking rates in the general adult population have declined, smoking remains entrenched among individuals with opioid use disorder (OUD). Individuals with OUD have an extremely high prevalence of smoking, experience poor cessation outcomes, and bear a disproportionate burden of smoking-related adverse health consequences. Data have also suggested that opioid-maintained (OM) smokers may experience a unique response to nicotine including heightened reinforcement and potentially more severe withdrawal when stopping smoking. Thus, this is a sub-group of smokers for which novel harm reduction paradigms are urgently needed to reduce the burden of smoking. A promising national policy is currently under consideration by the Food and Drug Administration to decrease the nicotine content of cigarettes in an effort to reduce smoking prevalence and smoking-related disease. It is critical to understand the extent to which reduced nicotine content cigarettes (RNCCs) can attenuate tobacco withdrawal severity in OM smokers as this has direct implications for the potential acceptability and uptake of reduced nicotine cigarettes in this vulnerable subgroup.

The primary aims of this study were to rigorously examine the effects of OM status on tobacco withdrawal and craving in response to participants’ usual brand cigarette and research cigarettes that varied in nicotine content. Opioid-maintained (OM; n=65) vs. non opioid-maintained (NOM; n=135) smokers completed 5 outpatient laboratory sessions in which they smoked a single research cigarette varying in nicotine content (0.4, 2.4, 5.2, 15.8 mg/g of tobacco) or their usual brand cigarette under double-blind, acute abstinence conditions. Participants completed the Minnesota Tobacco Withdrawal Scale before and every 15 minutes for one hour following smoking each cigarette. As an exploratory aim, we also examined the contribution of OM status to tobacco withdrawal in the context of several other important characteristics associated with smoking vulnerability (e.g., depression, anxiety, education level). Repeated measures mixed model analyses were used to examine all aims.

Across usual brand cigarettes and RNCCs, tobacco withdrawal and craving did not differ as a function of OM status (p’s >.05). In multivariable models, nicotine dose, time, depression, cigarette dependence, education level, but not OM status, consistently predicted tobacco withdrawal and craving severity (p’s <.05). In particular, depression severity, rather than OM status, was the strongest and most consistent predictor of withdrawal and craving severity among the characteristics examined.

Despite prior data suggesting that OM smokers may respond differently to nicotine and experience more severe withdrawal during reductions in nicotine intake, OM smokers in this study responded favorably to RNCCs. These findings provide additional support for the potential beneficial effects of a national nicotine reduction policy for reducing the burden of smoking and smoking-related consequences among smokers with concurrent OUD.