Health Disparities

Risk of initiating and escalating substance use may be heightened during adolescence due to several potential biological and social factors (e.g., neural plasticity during adolescence that may render the brain more sensitive to the effects of drugs of abuse, and peer influences that may promote drug use in social circles).

Notable Contributions:

• Substance use risk is elevated in teens who are more anhedonic,¹ impulsive,² depressed, ³ anxious,⁴ emotionally distressed,⁵ and those of lower SES.⁶
• Risk for smoking initiation related to emotional distress may be due in part to environmental factors and not solely genetics,⁷ but does tend to run in families.⁸
• Teen smokers indeed experience robust withdrawal symptoms when they stop smoking,⁹ just like adults.
• Novelty seeking may be a phenotypic marker for familial risk of adolescent substance use and sensitivity to the mood-altering effects of drugs, which predict more frequent substance use.¹⁰

Current and Future Directions:

• A 10-wave longitudinal cohort study of 3500 adolescents from 9th grade to 12th grade to investigate interrelations between transdiagnostic psychopathologic traits, substance use, diet, physical activity, alternative reinforcers, and sociocultural and psychological processes (R01-DA033296; PI-Leventhal).¹¹

Implications:

This work informs theoretical models regarding the development of psychopathology, substance use disorders, and their comorbidity. We also provide data relevant to designing psychosocial batteries for identifying teens who are at risk for substance use and other problems. Finally, this work informs the development of novel prevention interventions that teach adolescents skills for identifying fun substance-free activities without resorting to drug use, which may help to offset disparities in adolescent substance use.

Individuals of different ethnic or racial groups and SES differ on several dimensions that may alter one’s sensitivity to and value of the acute effects of drugs, including genetics (e.g., genetic variants that alter the pharmacodynamic response to drugs), ease of accessing drugs in the community, availability of healthy non-drug alternatives, social stress, and cultural factors (e.g., differences in the experience and expression of emotion). We investigate how these factors explain socioeconomic and ethnic disparities in substance use.

Notable Contributions:

• African American (vs. White and Hispanic) smokers report greater decreases in positive affect during tobacco withdrawal but do not differ in other tobacco withdrawal symptoms.¹
• Intersectionality of ethnicity and gender show that while White women smokers expect that smoking will help them with weight control more than White men, but African American women and men do not have such marked differences in beliefs regarding smoking’s effects on weight control.²
• Smoking in Korean-American young adults and Chinese adolescents may be particularly driven by negative affect, environmental (vs. genetic) factors and by peers of Asian (vs. other) decent.³
• Adult smokers of lower SES select smoking over alternative non-smoking rewards on behavioral economics choice procedures suggesting hyper-valuation of smoking.⁴
• Teens of lower SES may have less access to healthy fun alternatives outside of substance use and therefore may be more likely to resort to substance use as a source of pleasure, meaning, and reinforcement. ⁵

Current and Future Directions:

• A laboratory study examining variation in 50 genes implicated in mood, cognition, and nicotine metabolism as predictors of variation in the subjective, cognitive, and behavioral effects of tobacco deprivation in 800 African American smokers (American Cancer Society RSG-13-163-01; PI-Leventhal).
• In the above study, we are also measuring black identity, experience of discrimination, subjective social status, and neighborhood disorder to examine how these factors have incremental, overlapping, and possible synergistic influences with genetic variation on difficulty quitting smoking.

Implications:

This work points to key treatment targets (e.g., negative affect mitigation, smoking devaluation and alternative reinforcement enhancement through contingency management) that might facilitate addiction cessation and prevention among women, ethnic minorities, and socioeconomically-disadvantaged individuals subject to addiction-related health disparities.

People with mental health problems face two forces that increase vulnerability to smoking and other forms of drug use:

1. They experience various social disadvantages due to having a mental illness (e.g., social ostracization, discrimination).
2. The neuropathology underlying their mental illness may render them more sensitive to the acute reinforcing effects of drugs that probe the brain’s emotional and cognitive circuits.

To address the pervasive comorbidity between multiple forms of mental illness and tobacco addiction, we have focused on how smoking is functionally linked with “transdiagnostic” psychopathologic traits that are common to multiple psychiatric disorders and reflect core tendencies to dysfunctionally react to emotional stimuli. Example traits include anhedonia,¹ psychomotor agitation,² anxiety sensitivity,³ hostility,⁴ and impulsivity.⁵

Notable Contributions:

• Anhedonia (the inability to experience pleasure) is a unique and robust risk factor for smoking uptake⁶ and relapse during a cessation attempt over and above psychiatric diagnoses.⁷
• Anhedonic smokers experience profound deficits in reward processing upon stopping smoking,⁸ which diminish subjective pleasure,⁹ enhance urge to smoke,¹⁰ bias behavior towards pursuing drug-related rewards,¹¹ and hence, motivate smoking reinstatement to remediate such deficits.¹²
• Trandiagnostic traits enhance sensitivity to the acute mood-altering effects of tobacco administration and deprivation, over and above the concomitant impact of psychopathological symptoms.

Current and Future Directions:

• Development of a novel smoking cessation psychotherapy based on positive psychotherapy that enhances skills in obtaining pleasure through healthy means without resorting to smoking in research lead by collaborators at Brown (R01-CA156241, PI-Kahler).¹³
• Development of a novel transdiagnostic treatment that promotes skills for identifying healthy pleasurable substitutes for smoking, challenges anxiogenic fears of the effects of nicotine withdrawal, and increases capacity to tolerate abstinence distress in research lead by collaborators at Unviersity of Houston (R34-DA034741, PI-Zvolensky).

Implications:

Our research indicates that it is not the manifest symptoms of psychopathology per se that may underlie comorbidity with smoking and motivates a paradigm shift towards studying and treating cross-cutting traits in addiction science and practice. Such work could ultimately reduce disparities in smoking-related morbidity and mortality among the large population of individuals who suffer from various forms of mental health problems.

Women and men differ in biology (e.g., gonadal hormones), psychology (e.g., personality traits, risk of mental illness), and cultural factors (e.g., gender roles). Each of these contextual factors may modulate how women and men experience and value the acute effects of substance use and ultimately may explain gender disparities in addiction in the population.

Notable Contributions:

• Women (vs. men) are more likely to relapse when they quit smoking and experience more severe increases in negative affect when they stop smoking, but they do not differentially express other tobacco withdrawal symptoms.¹
• Negative affect and low positive affect are risk factors for adolescent girls smoking uptake, but only negative affect is associated with smoking uptake for adolescent boys.²
• • Women express stronger beliefs that smoking alleviates negative affect, and these beliefs are especially prominent for women with more severe premenstrual symptoms.³

Current and Future Directions:

• A laboratory study on the interactive effects of ovarian hormone variation and nicotine replacement pharmacotherapy on smoking motivation in female smokers (R21 DA034768; PI-Leventhal).
• An ecological momentary assessment study investigating ovarian hormones on smoking behavior of female smokers (K01 DA040043, PI-Pang).

Implications:

These data point to novel pharmacotherapeutic targets (e.g., progesterone agonists), shed light on phases of the menstrual cycle in which smoking cessation and nicotine replacement therapy might be most successful, and possibly elucidate psychosocial processes (e.g., rumination) that could be targeted in gender-specific smoking cessation psychotherapies that buffer negative affect during withdrawal.