Vertical farming offers several ways in which it can help the environment:

1. Land Conservation: Vertical farming utilizes vertical space to grow crops, reducing the need for extensive land use. By growing food in urban areas or on the outskirts of cities, it helps preserve valuable agricultural land and natural ecosystems from conversion into farmland.
2. Reduced Water Usage: Vertical farms typically employ efficient irrigation systems, such as hydroponics or aeroponics, which use significantly less water compared to traditional soil-based indoor vertical farming. These systems recirculate water, minimizing wastage and decreasing overall water consumption.
3. Decreased Dependency on Pesticides: In a controlled environment, vertical farms face fewer pest and disease challenges compared to outdoor farming. This reduces the need for chemical pesticides and fungicides, leading to a reduction in environmental pollution and the negative impact on ecosystems.
4. Energy Efficiency: Vertical farms utilize advanced lighting systems, such as LED lights, which consume less energy compared to traditional agricultural lighting sources. Additionally, climate control systems in vertical farms are designed to optimize energy usage by maintaining precise temperature and humidity levels.
5. Reduced Carbon Footprint: By bringing food production closer to urban areas, vertical farming reduces the distance food needs to travel from farm to consumer. This reduces transportation emissions associated with long-distance shipping, leading to a lower carbon footprint.
6. Soil Conservation: Vertical farming methods, such as hydroponics and aeroponics, eliminate the need for soil, thereby minimizing soil erosion and degradation. Soil erosion is a significant environmental concern associated with traditional agriculture, leading to loss of topsoil, nutrient runoff, and water pollution.
7. Biodiversity Preservation: By reducing the pressure to convert natural ecosystems into farmland, vertical farming contributes to the preservation of biodiversity. It helps protect wildlife habitats, supports pollinators, and maintains ecological balance by reducing deforestation and habitat destruction.
8. Sustainable Urban Development: Vertical farms can be integrated into urban areas, repurposing existing buildings or utilizing unused spaces. This promotes sustainable urban development by transforming underutilized or abandoned structures into productive agricultural spaces, enhancing the aesthetic value of cities and improving the overall urban environment.

By combining resource-efficient technologies, controlled environments, and sustainable agricultural practices, vertical harvest farms presents a promising solution to mitigate environmental challenges associated with conventional agriculture, contributing to a more sustainable and resilient food production system.

In cocaine-dependent subjects, lower FA was reported in inferiorfrontal white matter at the anterior-posterior commissure plane, in frontal white matter at the anterior commissure-posterior commissure plane, and in the genu and rostral body of the anterior corpus callosum. Similarly, lower FA in the right frontal white matter is also frequently reported in methamphet amine users and alcohol drinkers, and recently reported in chronic ketamine users. Convergent evidence suggests that chronic drug use is associated with decreased FA in white matter of the multiple brain regions, especially in the frontal lobe. Results of this study, along with previous findings, suggest increased FA, such that the effects of chronic cigarette smoking on brain white matter are different from effects of other addictive drugs. Increased FA may reflect increased maturation in cell packing density, fiber diameter, and directional coherence. A possible explanation for increased FA could be the variety of neurogenic properties of nicotine. In addition to maintaining and reinforcing smoking behavior, nicotine is reported to have other properties, such as anxiolytic properties and learning and memory-enhancing properties. Despite the proposal that chronic nicotine exposure may ultimately bring no benefits on mood and cognition, nicotine per se is known to be a neuroprotective agent, and prevents arachidonic acid induced injury to neurons and apoptotic cell death. Also, previous studies have revealed that nicotine upregulates calcium binding proteins, increases the levels of intracellular calcium measured and stimulates nerve growth factor,indoor grow rack which could also be neuroprotective. These previous reported neuropro tective effects could be consistent with increased FA from chronic cigarette smoking.

However, increased FA in white matter of brain in chronic cigarette smokers may not be beneficial. For example, Hoeft et al reported that increased FA of right superior longitudinal fasciculus in Williams syndrome individuals was associated with deficits in visuospatial construction. Similarly, a study of attention deficit hyperactivity disorder also found a correlation between increased FA with deficits in cognitive function. Increased FA is also reported in euthymic bipolar patients. Furthermore, evidence from previous studies reveals that increased FA could be a marker of acute inflammatory processes affecting neural tissue, indicating greater inflammation or less myelination. Thus, our result of increased FA in white matter might be associated with inflammatory changes and axonal damage in fronto-parietal cortex in chronic cigarette smokers. An alternate interpretation for increased FA in chronic cigarette smoking and some psychiatric disorders could be that they reflect the compensatory mechanisms and could be the result of increases in local white matter density. The higher FA found here is consistent with another study using DTI in 10 chronic cigarette smokers. However, we did not replicate their finding of increased FA in the body and whole corpus callosum in chronic cigarette smokers. Also, a recent study found that both prenatal exposure and adolescent exposure to tobacco smoke were associated with increased FA in anterior cortical white matter. Gazdzinski et al, examined the impact of smoking on alcohol-dependent individuals and found that the combination of cigarette smoking and alcohol dependence results in significantly larger volumes of temporal and frontal white matter; recently, they further confirmed the increased FA result in a abstinent smoking and non-smoking alcoholics study. However, Gons RA et al studied 503 small-vessel disease subjects aged between 50–85 years and found that cigarette smoking is associated with the reduction of FA in cerebral white matter.

Age, use of medical drugs and co-morbid medical conditions may the leading cause of the inconsistent results. In our study, increased FA was found in parietal-frontal white matter in the chronic cigarette smokers relative to healthy non-smokers. This discrepancy might arise from sample differences, such as differences in ethnicity, levels of cigarette smoking , age and psychiatric comorbidity . Results of our study indicate that the maintenance of cigarette smoking might involve fronto-parietal circuitry. Scientific evidence indicaties that the fronto-parietal cortex is one of the crucial units that functionally connects interrelated brain regions. Dosenbach et al indicated that this fronto-parietal circuitry initiates and adjusts control. There is also evidence that there is a network of frontal and parietal areas, which shows significant interactions between changes to a particular stimulus dimension and the current focus of attention. Findings from a previous study suggest that during nicotine withdrawal, functional integration of fronto-parietal networks is abnormal in cannabis users. Previous studies and our results may indicate altered connectivity within a cognitive network that is mediated by abnormal neurogenic functional activation in chronic nicotine exposure. In order to fully understand the mechanism of structural alteration in fronto-parietal cortex of chronic smoking, further studies using techniques such as adaptation or multi-voxel pattern analysis will be needed. A number of limitations to our study should be addressed. First of all, possible sex differences in the response to nicotine may exist. We did not evaluate sex differences because of the relatively small number of female participants, which is a limitation of the study, although we matched for the gender proportion between smokers and healthy non-smokers. Second, education level was significant ly higher in the nonsmoker group compared to the smoker group.

However, when we explicitly explored the impact of education level on bilateral fronto-parietal white matter in the smoker group, we found no significant correlation . This suggests that our findings cannot simply be explained in terms of this variable. In conclusion, our DTI data further support the hypothesis that smokers and non-smokers differed in bilateral fronto-parietal white matter integrity. These findings support the hypothesis that chronic cigarette smoking involves alteration of fronto-parietal connectivity.During the later part of the 1990s and into the first half of the current decade we have witnessed substantial reductions in the proportion of daily smokers among adolescents in the US. But according to a recent report by the Monitoring the Future survey, this trend is beginning to slow . Despite an overall decrease in tobacco use among adolescents in the United States, in 2005 over half of adolescents reported lifetime experimentation with smoking . Hispanic adolescents reported higher rates than non-Hispanic Whites and African Americans . Among adolescents, use of alcohol is more common than tobacco. This is true for all major ethnic groups. Hispanics have the highest rates of lifetime alcohol use ; rates among African Americans are lowest, and then non-Hispanic Whites . Racial/ethnic trends of marijuana use are similar to those for alcohol. Lifetime use of marijuana is highest for Hispanic adolescents . In California, the most populous state in the US, ethnic minorities surpassed whites as the majority population in 2000 . Increasing numbers of Latinos largely fueled this shift. Given the tremendous growth of this population there is a need for continued assessment of risk behaviors. Yet, research has been slow to adopt measurement and methodologies that are specific to the Latino population ,indoor farming equipment and still fewer have studied risk behaviors in Latino youth living in close proximity to an international border. Previous research has shown heightened rates of risk behaviors in border cities .Parenting, i.e., parenting practices, represents an area of significant influence in the area of adolescent risk behavior prevention . Parenting practices have been estimated to account for as much as 40% of the variance in children’s risk behaviors . In the early years of a child’s life, parents are the primary administrators of punishing and reinforcing stimuli in the child’s immediate environment, save the most basic biological contingencies . Administering contingent consequences can be a difficult job that requires surprising precision. Some of the common errors in parenting practices include inconsistent and poor timing of reinforcement and inappropriate timing and type of punishment . With the development of language, parents rely heavily on verbal stimuli to communicate contingencies to the child . This added component is an additional source of error in parenting practices. For example, the promise of a reward is very enticing, and the behavioral outcome is very desirable to parents. Such outcomes probably maintain the practice in parents. Nevertheless, after repeated errors the child quickly discriminates that the parent is “all talk”. Employing contingency management procedures imprecisely can lead to difficulties in child behavior and a developmental trend that potentially escalates problem behavior. When used appropriately, however, these strategies can establish pro-social skills and support children to, for example, avoid alcohol, tobacco and other drugs . Parents of children who are non-compliant often demonstrate poor contingency management, including inconsistent discipline and poor monitoring . Parent reactions to child behavior, often in the form of reactive parenting, can shape anti social or undesirable practices . Imprecise contingency management can lead to difficulties in behavior and a developmental trend that can escalate problem behavior . In cases of deteriorating parent-child relationship, adolescents who are further along the risk continuum may be more susceptible to peer influences to initiate risk practices .

This parallels the concept of motivating operations , one that is highlighted in the applied behavior analysis literature. One of the pioneering figures in the field, Jack Michael, defines the concept as an environmental event, operation, or stimulus condition that affects behavior by altering the magnitude or direction of effect for contingent consequences . Operationally in this context, in the teenage years adolescents are exposed to stimuli that enhance the reinforcing effect of peers. The contrary is also true: there is a tendency for parents’ reinforcing effect to diminish during these critical years. One possible antidote is for parents to increase positive involvement in their child’s life so they can differentially change the frequencies of certain behaviors as a function of the value of the contingent punishing or reinforcing stimuli they deliver. To the extent to which they can do this, they may be able to buffer environmental influences that increase risk for certain risk behaviors . In children as young as middle school, where reported alcohol rates exceed 50%, tobacco 20% and marijuana 12%, parental influence has at least been shown to reduce risks for alcohol use . Much of the research in parenting and parenting practices has involved an assessment of the parent’s behavior as reported by their children and is usually collected through interviews and questionnaires. Such practices and measures have high face validity, but they have inherent weaknesses, as they are generally limited to self-report. Interviews and questionnaires are not ideal measures, no matter whether it is the child or the parent that responds. Alternatives to self-report measures may include direct observation, either in person or with the use of video equipment. In light of the additional expense of direct observation, select few researchers have expanded their research to include responses from both the parent and the child. The justification for this approach derives from the notion that effects of parenting practices should be centered on the children’s own perspectives. Nevertheless, recent details have emerged about a learning or socialization process in which parents and children have reciprocal behavioral influences, i.e., parents influence kid’s behavior, and kids also influence parent’s behavior . From this perspective, an assessment of the parents’ practices from their own point of view and that of their children may be warranted . A more complete understanding of parental influence must be preceded by an increased understanding of the discrepancies between parents’ and children’s reports of parenting behaviors . Consistent with this perspective, recent studies have shown that discrepancies in perceptions between adolescents and their parents may be negatively related to adolescent adjustment , including increased levels of conflict and stress within the family resulting in a myriad of problem behaviors . The limited number of studies comparing parents’ and children’s reports of parenting behaviors reveal that parents frequently overestimate their involvement, especially in monitoring and discipline . Involvement in school can encompass several areas including regular attendance, academic achievement and academic clubs, sports, and other extracurricular activities.Engagement in any of these school activities is negatively associated with initiating alcohol use . In general, being more active in school has been associated with an attenuated probability for participation in risky behaviors . School performance has been shown to be negatively associated with smoking initiation among non-Hispanic whites and Hispanics . Around the onset of puberty, peer influence becomes more salient and powerful, both because of modeling effects and peer reinforcement . For example, having at least one smoking peer greatly increases risk for smoking initiation and progression to daily smoking .

PCC measures are used to explain changes in alcohol-related mortality and morbidity , for comparison of alcohol use across geographic regions , the study of alcohol policies , the examination of alcohol use over time, the calculation of global alcohol-attributable fractions, and to inform news articles about alcohol use in the U.S. . It is therefore critical that PCC measures are as precise as possible to ensure that conclusions drawn from the applications of these measures are accurate and valid. Through the presentation of estimates based on ABV variation and comparisons to estimates from ABV-invariant methods we suggest that the inclusion of annual estimates of the %ABV of alcoholic beverages sold in the U.S. is necessary to ensure the precision of PCC measures and the accurate detection of changes in alcohol consumption over time and place. Drugs that activate cannabinoid receptors, the molecular target of Δ 9 -tetrahydrocannabinol in marijuana, reduce nausea and emesis produced by chemotherapy , alleviate pain symptoms associated with central and peripheral neuropathies , decrease pain and spasticity in multiple sclerosis , and improve psychomotor deficits in Tourette’s syndrome . Despite such broad therapeutic potential, the clinical usefulness of these agents is limited by their psychotropic and reinforcing effects,grow benches which account for the remarkable prevalence of marijuana as an abused drug . The rewarding properties of plant-derived or synthetic cannabinoid drugs are reasonably well understood.

Mechanistically, they have been linked to the ability of these substances to activate CB1-type cannabinoid receptors in the central nervous system, enhance activity of midbrain dopaminergic neurons, and elicit dopamine release in the reward-controlling shell region of the nucleus accumbens . By contrast, the contribution of endocannabinoid signals to the regulation of normative reward-based behaviors is still unclear, despite indications that pharmacological or genetic interruption of CB1 receptor activity strongly affects such behaviors . One important set of questions that remains unanswered relates to the chemical neuroanatomy of endocannabinoid-mediated reward and, in particular, to the functions served by individual endocannabinoid substances in reward modulation. Two such substances have been characterized: anandamide and 2-arachidonoylglycerol .Both compounds are produced in and released from neuronal and glial cells upon demand, and are eliminated by uptake into cells followed by intracellular hydrolysis. In the brain, anandamide is primarily hydrolyzed by the postsynaptic membrane-associated amidase, fatty acid amide hydrolase , which also cleaves other non-cannabinoid fatty-acid ethanolamides such as oleoylethanolamide . On the other hand, 2-AG is predominantly hydrolyzed by the presynaptic cytosolic lipase, monoacylglycerol lipase and, to a lesser extent, by two additional membrane-associated lipases, ABHD6 and ABHD12 . The existence of distinct biochemical pathways mediating the deactivation of anandamide and 2-AG suggests that selective pharmacological interruption of each of these pathways might help define the contribution of individual endocannabinoid signals to the modulation of reward. The compound URB597 is a potent and selective inhibitor of intracellular FAAH activity . In rodents, URB597 increases brain anandamide levels without changing the levels of 2-AG . Moreover, the drug elicits antinociceptive, anxiolytic-like, and antidepressant-like effects , which are likely mediated by enhanced anandamide activity at CB1 receptors, because they are attenuated by the CB1 antagonists rimonabant and AM251 .

Importantly, URB597 does not cause place preference or substitute for THC in rat drug-discrimination tests, an indication that it may lack hedonic properties . In the present study, we investigated the rewarding properties of URB597 in squirrel monkeys, a primate species that has been extensively used to model human reward-based behavior and has provided precious insights into the reinforcing effects of cannabinoids . We first determined the effects of URB597 on endocannabinoid levels in areas of the brain associated with reward, memory and emotional responses to stress. Next, we tested whether URB597 would either be self-administered by monkeys or would alter their self-administration of THC and cocaine. Finally, to assess the potential of URB597 to precipitate relapse to abuse in abstinent individuals, we examined its ability to reinstate extinguished drug-seeking behavior. Twenty three adult male squirrel monkeys weighing 0.9 to 1.1 kg were housed in individual cages in a temperature- and humidity-controlled room with unrestricted access to water. Monkeys were fed a daily ration consisting of five biscuits of high protein monkey diet and two pieces of Banana Softies that maintained their body weights at a constant level throughout the study. Fresh fruits, vegetables and environmental enrichment were provided daily. One group of five monkeys was used for experiments with the anandamide self-administration baseline: all monkeys had a history of anandamide self-administration . Another group of four monkeys was used for experiments with the THC self administration baseline: three monkeys had a history of THC self-administration and one monkey had history of anandamide self-administration . Another group of four monkeys was used for experiments with the cocaine self-administration baseline; all monkeys had a history of cocaine self-administration . A group of ten monkeys with no prior exposure to cannabinoids was used for neurochemical analyses . Adult male Wistar rats , n = 6–12 per group, were used for evaluation of brain lipid levels in rats. The animals were housed at constant room temperature and humidity under a 12-h light/dark cycle. Food and water were available ad libitum. Monkeys and rats were maintained in facilities fully accredited by AALAC and experiments were conducted in accordance with guidelines of the Institutional Animal Care and Use Committee of the Intramural Research Program, NIDA, NIH, and followed the Guidelines for the Care and Use of Mammals in Neuroscience and Behavioral Research .

Experimental chambers and other apparatus used in this study were the same as previously described . Monkeys were surgically prepared with chronic indwelling venous catheters . The catheters were connected to polyethylene tubing, which passed out of the isolation chamber where it was attached to a motor-driven syringe pump. Before the start of each session, monkeys were placed into Plexiglas chairs and restrained in the seated position by waist locks. Before each session, catheters were flushed with 1 ml of saline and one priming injection was delivered . At the start of the session, the white house light was turned off and green stimulus lights were turned on. In the presence of the green lights,grow racks with lights monkeys were required to make 10 responses on a lever to produce an injection of anandamide, THC or cocaine. Completion of 10 responses on the lever turned off the green lights and produced an intravenous injection of 40 µg/kg of anandamide, 4 µg/kg of THC or 30 µg/kg of cocaine paired with a 2-s illumination of amber stimulus lights . Duration of each injection was 0.2 s and injection volume was 0.2 ml. Each injection was followed by a 60-s timeout period, during which the chamber was dark and lever presses had no programmed consequences. One-hour sessions were conducted five days per week . All monkeys had learned to respond under the FR10 schedule for the particular training drug prior to beginning this study. After completing the previous experiments, monkeys self administered the training dose of each drug for at least five sessions until responding was stable . Self administration behavior was then extinguished by substituting vehicle for THC, anandamide, or cocaine, but maintaining the presentation of the brief-stimulus associated with each injection. Then we tested reinstatement of extinguished drug-taking behavior by priming injections of THC or URB597 in all three groups of monkeys. Reinstatement effects of each pretreatment were studied for three consecutive sessions starting after at least three days of stable vehicle extinction. Monkeys received injections of vehicle or URB597 in their home cage. THC was injected in the chair immediately before the session.Food was withheld 12 h prior to this procedure. Anaesthesia was induced and maintained with isoflurane . Monkeys were weighed, prepared with a venous line , placed on a surgery table and kept warm by heat lamps. Body temperature and ECG were monitored throughout anaesthesia. After animals were stabilized , URB597 or its vehicle was intravenously injected 1 h prior to euthanasia and the venous line was flushed with 0.5 ml of saline. Body temperature, SPO2, pulse and rate of respiration were recorded every 10 min. After 1 h, monkeys were euthanized with Euthasol .Brains were quickly removed, the cerebella were separated and forebrains were dissected.

Each hemisphere was cut into 3 parts by two coronal sections made at approximately AP +12.5 and −5 . Brain fragments were snap-frozen in isopentane , wrapped in aluminium foil, and placed in dry ice. Samples were stored in the freezer for 2 days and then shipped on dry ice to the University of California Irvine for analyses. In one set of experiments, rats were sacrificed by rapid decapitation under light anaesthesia 2 h after injection of URB597 or vehicle. In other experiments, rats were food deprived for 12 h and sacrificed by decapitation 1 h after injection of URB597 or vehicle, while maintained under isoflurane anaesthesia for the duration of the experiment. In either case, brains were rapidly removed, and the hippocampus and prefrontal cortex was dissected from the fresh tissue over ice. Brain regions were frozen in dry ice, and stored at −80°C until lipid and enzymatic analyses. Cumulative-response records were obtained during all sessions to assess within-session patterns of responding. Rates of responding during self-administration sessions are expressed as responses per second averaged over the one-hour session, with responding during time-outs not included in calculations. Injections per session represent total number of injections delivered per session. Data for dose-effect curves are expressed as mean response rates and numbers of injections per session ± SEM over the last three sessions. In addition, total intake of anandamide, THC or cocaine for each session was calculated. Reinstatement data and effects of pretreatment with URB597 on drug self-administration are expressed as mean ± SEM of total numbers of injections per session over three sessions. Statistical analysis was done using single-factor repeated measures ANOVA to assess differences between vehicle and test-drug pretreatment conditions or between different doses of anandamide, THC, cocaine or URB597 and vehicle. Significant main effects were analyzed further by subsequent paired comparisons to control values using Dunnett’s test . Bonferroni t-test was used when the number of observations did not allow for the use of the Dunnett’s test. Differences between effects of vehicle and URB597 pretreatment on lipid levels and FAAH activity were analyzed using single-factor ANOVA. Differences were considered statistically significant when p < 0.05.We found that the selective FAAH inhibitor URB597 suppresses FAAH activity and increases anandamide levels in regions of the squirrel monkey brain that participate in motivational, cognitive and emotional functions. This effect is accompanied by a marked decrease in the levels of 2-AG, a major endocannabinoid substance in the brain, even though URB597 does not affect activities of 2-AG-metabolizing enzymes such as DGL and MGL. We further observed that URB597 does not display overt reinforcing property in monkeys over a broad range of experimental conditions. Indeed, the drug did not reinforce self-administration behavior even when its cumulative intake exceeded by several folds a fully effective dose for FAAH inhibition. Furthermore, neither previous cocaine nor THC exposure predisposed monkeys to self-administer URB597: even monkeys that had previously self-administered anandamide at very high rates failed to respond to the FAAH inhibitor. Lastly, URB597 did not affect the reinforcing effects of THC or cocaine, and did not reinstate extinguished drug seeking behavior in monkeys that had previously self-administered THC or cocaine. We interpret these results to indicate that URB597, by enhancing anandamide signaling, causes a compensatory down-regulation in 2-AG mobilization; and the potentiation of anandamide-mediated transmission produced by URB597 is insufficient per se to produce reinforcing effects. Our findings further imply that FAAH inhibitors such as URB597 – which have demonstrated analgesic, anxiolytic, antidepressant and antihypertensive properties in rodents – may be used in humans without anticipated risk of inducing abuse or provoking relapse to drug use in abstinent individuals. The pharmacological profile of URB597 is strikingly different from that of THC and other direct-acting CB1 receptor agonists. Studies in rodents have shown that URB597 does notproduce THC-like effects such as catalepsy, hypothermia or hyperphagia . Further, URB597 does not mimic the discriminative-stimulus actions of THC . Even further, URB597 does not increase dopamine levels in the nucleus accumbens shell of rats, a defining neurochemical feature of reinforcing drugs . Finally, URB597 does not elicit conditioned place preferences indicative of rewarding properties in rats .

Such a mechanism could be of value when semantic information has a higher priority than spatial data. Finally, the present evidence for biased CB1R signaling has significant implications for hypotheses about how marijuana influences cognition. The Δ9 -tetrahydrocannabinol component of cannabis is an agonist for CB1Rs and stimulates the production of pregnenolone ; results presented here indicate that the combination of CB1R stimulation and high levels of pregnenolone will lower the requirements for robust lppLTP and the encoding of near threshold cues. It is interesting regarding this possibility that marijuana promotes the formation of false memories in episodic memory tests . In all, the differential effects of CB1R stimulation across the principal nodes of hippocampal circuitry are predicted to underlie a distortion of episodic memory with cannabis expo sure that is due to enhanced plasticity in the LPP.Alcohol problems typically develop in late adolescence and early adulthood, though they can manifest at any time during adult life. Early age at first drink has been shown in many analyses to be a powerful predictor of an alcohol use disorder . Family history of alcohol dependence is known to increase risk by at least two fold. Males are more likely than females to develop alcohol use disorders , and this is true within families of alcohol-dependent probands as well as the general population . Recent data have shown that, in the US, African Americans are less likely to develop an AUD than European- Americans though analysis over different age groups suggests that a different developmental course may characterize AUDs in African-Americans,bud drying rack with relatively later onset of disorders in comparison to EA groups . It must be borne in mind that these rates are a moving target and there is evidence for relative increases of AUD in women and AA subjects compared to EA males over recent years . There is also a known risk relationship between other psychiatric disorders and alcohol use disorders.

Persons with a mood disorder have an increased lifetime risk for an alcohol use disorder, as compared with persons without mood disorders . The increased risk for a substance use disorder following onset of a mood disorder is perhaps most precisely demonstrated by Plana Ripoll et al. 2019, using a study of the Danish population that showed a cumulative risk of 20% for men and 10% for women for an SUD during the fifteen years following the onset of a mood disorder. This represents a hazard ratio of ~5 for a disorder severe enough to come to clinical attention. Adolescents with a mood disorder are at increased risk for onset of alcohol problems and vice versa . Mood disorder may be associated with the course of alcohol problems as well as onset . Scores on an internalizing scale were correlated with risk for alcohol and other drug use disorders in a prior analysis of the Collaborative Study on the Genetics of Alcoholism subjects . There is an extensive literature supporting the relationship of externalizing disorders to subsequent development of AUDs and this has formed the basis of certain typologies of AUD, including Types 1 and 2 and Types A and B . Type 2 subjects are characterized by high novelty seeking, low harm avoidance, and low reward dependence . They are more likely to be diagnosed with antisocial personality disorder and less likely to be able to abstain from alcohol. Type B subjects are more likely to have a history of childhood aggression and conduct disorder and less likely to have a sustained response to treatment in comparison to Type A subjects . More recent studies also emphasize the role of externalizing disorders, such as conduct disorder and attention deficit hyperactivity disorder in increasing the risk for alcohol problems.We studied a sample at risk for the development of alcohol use disorder on the basis of family history. Initial assessment was done on all subjects in the age range 12–21. These subjects have been followed over time with assessments every two years for up to 10 years.

The present report evaluates the relationship of comorbid externalizing and internalizing disorders to age of onset of an AUD in a group of adolescents/young adults at high risk for AUDs. We also compare the onset of two alcohol milestones in groups divided by AUD severity. We hypothesized that persons developing AUDs following the onset of externalizing and internalizing disorders would show earlier onset than those without those baseline disorders. We also hypothesized that more severe AUDs would show an earlier onset of alcohol-related developmental milestones such as age of first drink and age of first regular drinking. The present report is one of the first we are aware of that tracks the development of AUDs in the context of multiple comorbid disorders in a high risk group, and it shows that some subjects are at great risk for alcohol problems in very early adolescence.Our subjects were participants in the adolescent to young adult Prospective sample of COGA . The COGA study started in 1989 and families were recruited between 1989 and 1995. Each family was recruited through a proband with an alcohol use disorder , targeting successive admissions to treatment facilities. There was a family size requirement with the idea of prioritizing larger families. All first-degree relatives were interviewed and families were extended through affected subjects . The subjects in the present study were offspring of the proband . The response rate for recruitment was about 70% or more . More information about the COGA study may be found in Bucholz et al., 2017 and Reich et al., 1998. All offspring in the age range at the start of follow-up were included. Offspring reaching the age of 12 during the course of the study were also included. Subjects were interviewed at two-year intervals with the Semi-Structured Assessment for the Genetics of Alcoholism interview Bucholz et al., 1994. The mean age at first interview was 16.1 and the mean age at last interview 23.1 . Subjects had an average of 4.0 interviews . 50.9% were female, 64.9% were EA and 30.9% AA. Ethnicity was assigned based on genotypic data,grow solutions greenhouse or by self-report if genotypes were not available. Subjects were members of a case family or a comparison family .

Non-drinkers were not excluded from the sample. The study was approved by The Indiana University Institutional Review Board . Written informed consent for the research was obtained from all participants in the study. All subjects in the study were invited to participate in interviews at two-year intervals. Detailed information on participation is provided in Bucholz et al., 2017. Information on all available interviews for each subject was combined in the present analysis with age of onset assigned according to the earliest description of psychopathology and a judgment of severity based on the time when the most symptoms were described. Every subject with at least one complete interview was included in the analysis. DSM-IV diagnoses for all disorders were made algorithmically from SSAGA information. However for these analyses we also generated a DSM-5 diagnosis for AUD in the following way. Individual alcohol symptoms were queried, starting with symptoms of DSM-IV alcohol dependence and alcohol abuse, adding craving and subtracting legal problems related to alcohol. Onset and offset of each symptom was recorded, making it possible to cluster symptoms that occurred by age. Thus the analyses presented here use DSM-5 AUD as an outcome variable while all other disorders are diagnosed by DSM-IV. Diagnoses of externalizing and internalizing disorders at the baseline interview were also made algorithmically from the SSAGA using DSM-IV. Externalizing disorders included any of the following: ADHD, conduct disorder/antisocial personality disorder, oppositional defiant disorder, drug use disorder . Internalizing disorders included major depression, panic disorder, obsessive-compulsive disorder, social phobia, and agoraphobia. Age of onset was determined for all comorbid disorders based on the SSAGA-IV. Subjects were divided into groups based on whether they had an externalizing disorder or an internalizing disorder at the time of the baseline interview. The groups were: Externalizing, Internalizing, Both, or Neither. Alcohol use disorder diagnosis was then assessed at each interview period, using the DSM 5 distinctions for Mild AUD , Moderate AUD , and Severe AUD . Subjects with age of onset of AUD prior to age of onset of internalizing/externalizing disorders were excluded from analysis.

We also performed a sensitivity analysis in which all subjects with externalizing were compared with all subjects without externalizing; likewise subjects with internalizing were compared with all subjects without internalizing . An externalizing-internalizing interaction term was included in this analysis. Overall, 43.0% of the sample met criteria for a diagnosis of either Mild, Moderate, or Severe AUD by the end of the observation period . At the time of the baseline interview, 982/3286 subjects had an externalizing diagnosis ; 140/3286 subjects had an internalizing diagnosis , 286 had both and 1878 had neither . All covariates had significant relationships to age of onset in subjects with either mild, moderate, or severe AUD . The association of any comorbid disorder and presence of Alcohol Use Disorder was significant overall , and there was a significant effect of comorbidity on age of onset as well . Among subjects with an externalizing disorder only at baseline, 515/982 had some type of AUD during the follow-up period. Among subjects with an internalizing disorder only at baseline 66/140 had an AUD. Among subjects with both externalizing and internalizing, 182/286 had an AUD. In comparison, subjects with neither type of disorder had an AUD rate of 34.7% . Figure 1 shows onset of alcohol use disorders in subjects stratified by initial diagnoses of Externalizing disorder, Internalizing disorder, Both, or Neither. Figures 1a–c show onset of mild, moderate, and severe AUDs respectively. For each type of AUD, the relationship with comorbid disorders is significant by Log-rank test and Cox Proportional Hazards . Age of onset comparisons are shown in Kaplan-Meier Plots . Each of these shows significant effects of comorbidity by Log-rank Test . The plots do not include a covariate effect but we have also achieved similar results by the Cox model adjusting for covariate effects . The statistical effect of comorbidity is generally greatest in the development of Severe AUD and least in Mild AUD based on the hazard ratios in the different comorbidity types . The three groups are significantly different from each other in the strength of the comorbidity effect . The sensitivity analysis showed a clear effect of externalizing on age of onset in mild AUD, moderate AUD, and severe AUD . For internalizing, there was an effect in moderate AUD and severe AUD . No statistical interaction was seen between the effect of externalizing and the effect of internalizing. Age of onset distributions are presented for Mild AUD , Moderate AUD , and Severe AUD . The distributions include drinking milestones as well as onset ages for the diagnoses of Mild AUD , Moderate AUD and Severe AUD . As noted above, the study samples are independent of each other for analytic purposes, and are classified according to the most severe disorder that the subject met criteria for during the observation period. Figure 2 shows drinking milestones in subjects who developed an alcohol use disorder. Figure 2a–c show mean, median, interquartile range, and outliers for subjects with mild , moderate and severe alcohol use disorder. Subjects are classified in a cohort according to the most severe form of disorder they manifested during the observation period. In Figure 2b milestones for the moderate group include the age when they would have been first classified as showing a mild AUD. In Figure 2c milestones for the severe group include the ages when they would have been first classified as showing a mild or moderate AUD. We used ANOVA and i-test to detect the correlation between the onset of drinking milestones in the four diagnostic groups. The mean age of first drink progresses from 16.2 in Unaffected to 14.9 in Mild to 14.4 in Moderate to 12.8 in Severe . The mean age of first regular drinking progresses from 18.8 in Unaffected to 17.5 in Mild to 16.9 in Moderate to 15.7 in Severe . The mean age for meeting criteria for Mild AUD progresses from 18.6 in Mild to 17.4 in Moderate to 16.1 in Severe .

There is considerable heterogeneity, however, in profiles of neurocognitive functioning across individuals with HIV and AUD . Patterns of alcohol consumption rarely remain static throughout the course of an AUD, but rather are often characterized by discrete periods of heavy use. This episodic pattern of heavy consumption may similarly impact the stability of HIV disease , which may in part explain why some PWH with AUD exhibit substantial neurocognitive deficits while others remain neurocognitively intact. Self-report estimates of alcohol use, however, often fail to predict neurocognitive performance . Methods for quantifying heavy drinking are also inconsistent across studies. For example, some studies classify individuals based on DSM criteria for AUD whereas others define heavy drinking based on “high-risk” patterns of weekly consumption . These methods characterize the chronicity of drinking and psychosocial aspects of alcohol misuse, but they are sub-optimal for quantifying discrete periods of heavy exposure and high level intoxication that may confer higher risk for neurocognitive dysfunction. Binge drinking, defined by the National Institute on Alcohol Abuse and Alcoholism as 4 or more drinks for women and 5 or more drinks for men within approximately 2 hours, may more precisely capture discrete episodes of heavy exposure. The relationship between binge drinking and neurocognitive functioning remains poorly understood across the lifespan and particularly in the context of HIV. Thus, the current study examined two primary aims to better understand the impacts of HIV, binge drinking,plants racks and age on neurocognitive functioning. The first study aim examined the independent and interactive effects of HIV and binge drinking on global and domain-specific neurocognitive functioning.

We hypothesized that: 1) neurocognitive performance would be poorer with each additional risk factor such that the HIV-/Binge- group would exhibit the best neurocognition, followed by the single-risk groups , and finally the dual-risk group; and 2) these group differences would be explained by a detrimental synergistic effect of HIV and binge drinking on neurocognition. The second study aim examined whether the strength of the association between age and neurocognition differed by HIV/Binge group. We hypothesized that: 1) older age would relate to poorer neurocognition; and 2) that this negative relationship would be strongest in the HIV+/Binge+ group.Participants included 85 PWH and 61 HIV- adults who reported drinking alcohol in the 30 day period prior to their study visit. Participants were further stratified based on their recent binge drinking status, resulting in the following four groups: HIV+/Binge+ , HIV-/Binge+ , HIV+/Binge- , HIV-/Binge- . All participants were enrolled in NIH-funded research studies at the University of California, San Diego’s HIV Neurobehavioral Research Program, and gave written informed consent as approved by the UCSD Institutional Review Board. The current cross-sectional study is a secondary analysis of data from each participant’s baseline visit at the HIV Neurobehavioral Research Program from 2003-2019. Exclusion criteria for the current analysis were: 1) current diagnosis of non-alcohol substance use disorders ; 2) diagnosis of psychotic or mood disorder with psychotic features; 3) presence of a neurological or medical condition that may negatively affect cognitive functioning, such as traumatic brain injury, stroke, or epilepsy; 4) positive urine toxicology for illicit drugs or positive Breathalyzer test for alcohol on the day of study visit; 5) report of no “recent” alcohol consumption . A modified timeline follow-back interview was used to assess drinking behavior in the last 30 days . Binge drinking was assessed per NIAAA criteria for binge drinking . Binge drinking behavior was dichotomized such that participants who had any binge drinking episode in the last 30 days were classified as binge drinkers .

Lifetime history of alcohol exposure, including quantity and frequency, was assessed via a semi-structured timeline follow-back interview that evaluates drinking patterns across different periods in an individual’s life. Current depressive symptoms were assessed using the Beck Depression Inventory-II, a self-report measure . The Composite International Diagnostic Interview was administered to evaluate current and lifetime mood and SUDs . Notably, the parent grants from which baseline data were drawn were funded prior to the publication of the DSM 5. Therefore, diagnoses were made in accordance with DSM-IV criteria where alcohol/substance abuse is met when participants report recurring problems as a result of continued alcohol/substance use; and alcohol/substance dependence is met when participants experience symptoms of tolerance, withdrawal, and/or compromised control over their alcohol/substance use . In order to remain consistent with the current DSM 5 criteria and nomenclature, alcohol/substance abuse and dependence criteria were combined to capture AUD and SUD. Participants were tested for HIV by enzyme-linked immunosorbent assay with Western Blot confirmation. All participants completed a comprehensive medical evaluation including self-report measures, structured neurological and medical evaluations, and blood samples to assess the presence of medical comorbidities and HIV disease characteristics. HIV viral load in plasma was measured using reverse transcriptase-polymerase chain reaction , where viral load was deemed undetectable below 50 copies/mL. Participants were administered a comprehensive battery of neurocognitive assessments measuring global and domain-specific neurocognitive performance: global function, verbal fluency, executive function, processing speed, learning, delayed recall, working memory, and motor skills . Raw scores from each neuropsychological test were converted into demographically-corrected T-scores .

Global and domain-specific continuous T-scores were derived from averaging the demographically-corrected T-scores across all tests and within each neurocognitive domain, respectively . These global and domain-specific T-scores were used as primary outcomes for comparisons of neurocognition between HIV/Binge groups. Demographic, psychiatric, medical, alcohol and substance use, and HIV disease characteristics were compared between the four HIV/Binge groups using analysis of variance or chi-square tests, as appropriate. Pair-wise comparisons were conducted to follow up on significant omnibus results using Tukey’s Honest Significant Difference tests for continuous outcomes or Bonferroni adjustments for categorical outcomes.To examine the first study aim, one-way ANOVA and Tukey’s HSD tests were used to compare mean global and domain neurocognitive T-scores between the four HIV/binge drinking groups. For any significant one-way ANOVA result, a 2 x 2 factorial ANCOVA was used to model independent and interactive effects of HIV and binge drinking status,plant growing trays covarying for total drinks consumed in the last 30 days and any demographic or non-alcohol-related clinical characteristics that differed between groups at p<0.05 . These demographic covariates were included to increase confidence that any observed difference in neurocognition between HIV/Binge groups would not be attributable to confounding effects of age and sex that may that may exist above and beyond the T-scores’ demographic corrections. To further support any findings indicating additive main effects, Jonckheere-Terpstra tests for ordered alternatives examined whether there was a statistically significant negative relationship between the number of risk factors and neurocognitive performance . Finally, to examine the second study aim, multiple linear regressions modeled the interaction between age and HIV/Binge status group on global and domain-specific T-scores, also covarying for total drinks consumed in the last 30 days, sex, and lifetime history of non-alcohol. Our examination of age as a predictor of demographically-corrected T-scores will allow understanding of how the effect of age in certain vulnerable groups may go above and beyond that of normal controls on whom demographic corrections were based. Parametric statistics were used because the outcome variables were continuous and had normal distributions in each HIV/Binge group. All analyses were performed using R, version 3.5.0.Demographic and clinical factors by HIV/Binge group are displayed in Table 1. The HIV-/Binge- group was younger than both HIV+ groups , and the HIV+/Binge+ grouphad a higher proportion of men compared to the two HIV- groups .

Regarding alcohol and substance use characteristics, the two Binge+ groups had significantly higher quantity and frequency of alcohol use in the last 30 days, higher proportions of current and lifetime AUD, higher lifetime quantity and frequency of alcohol use, and a higher proportion of lifetime non alcohol SUDs compared to those of both Binge- groups . Alcohol use characteristics, including frequency of alcohol binges in the last 30 days, did not differ between the HIV-/Binge+ and HIV+/Binge+ groups . For each of those neurocognitive outcomes with a significant omnibus result, follow-up pairwise comparisons showed significant differences between only the HIV-/Binge- and the HIV+/Binge+ groups, with HIV+/Binge+ participants exhibiting poorer performance . Results of the 2 x 2 factorial ANCOVAs are shown in Table 2. Additive main effects of HIV status and binge drinking status were detected on global function and processing speed, however none of the interactions between HIV and binge drinking status on neurocognitive outcomes reached statistical significance. Additive main effects of HIV and binge drinking were further supported by results from Jonckheere-Terpstra tests indicating significantly lower global and processing speed performance by each increase in risk factor count . Binge drinking was also a significant predictor of delayed recall and working memory. Of note, the effects of binge drinking on neurocognition were not attenuated by accounting for total drinks in the last 30 days, which did not significantly relate to any neurocognitive outcome .Given the rapidly growing population of older adults with and without HIV along with the increased rates of binge drinking among them, studying the combined effects of HIV and binge drinking across the lifespan is timely and important. Partially consistent with our first hypothesis, the HIV+/Binge+ group demonstrated the worst global neurocognitive functioning ; however, the combined effects of HIV and binge drinking on global neurocognitive functioning exhibited an additive, rather than synergistic, pattern . Consistent with our second hypothesis, we found a novel interaction with age and HIV/Binge drinking group such that the HIV+/Binge+ group displayed a stronger negative relationship between age and three domain-specific neurocognitive outcomes compared to the HIV-/Binge- group. Importantly, the alcohol-related detriments to neurocognition appeared to be specific to binge drinking, as total 30-day alcohol consumption was not a significant independent predictor of any neurocognitive outcome in our statistical models. These findings suggest that recent, discrete episodes of heavy alcohol exposure relate to poorer brain function and highlight the need for interventions to reduce binge drinking behavior among PWH, especially older PWH, in order to promote cognitive health. The findings showing additive main effects of HIV and binge drinking are consistent with several other studies demonstrating additive, but not synergistic, effects of HIV and heavy alcohol use on neurocognitive functioning . In fact, there is only one study to our knowledge that has shown an interactive effect of HIV and heavy alcohol on neurocognition, specifically in the domains of motor and visuomotor speed . Our finding of HIV/Binge group differences in neurocognitive domains of processing speed, delayed recall, and working memory is also consistent with the frontostriatal and frontolimbic neural damage that has been observed in studies of adults with HIV and heavy alcohol use . As briefly discussed, there are a number of possible mechanisms underlying the relationship between heavy alcohol use and adverse neurocognitive outcomes in HIV, including those related to antiretroviral therapy ; possible pharmacokinetic interactions with alcohol . Recent research, however, has revealed neuroinflammatory and neuro-immunological effects as major pathways underlying the relationship between heavy alcohol use and neurobiological damage , with several of these neuroimmune pathways overlapping with effects from HIV . Although these immunobiological underpinnings are still poorly understood in the context of comorbid HIV and heavy drinking, this represents an important line of research needed to develop potential targeted interventions for reducing the incidence and/or severity of neurocognitive impairment in this population. The current study also uniquely found that the negative relationship between age and neurocognitive functioning was steepest among the PWH who reported binge drinking in the last 30 days, particularly in the domains of learning, delayed recall, and motor skills. Our findings are consistent with what is known about the greater vulnerability to brain atrophy and neurocognitive deficits in older PWH and older adults who drink heavily . Furthermore, this result showing an age by HIV/Binge group interaction is also similar to findings from a previous study in which age was found to be a significant predictor of demographically-corrected episodic memory scores only among individuals with comorbid HIV and AUD . Speculation about accelerated aging or neurocognitive decline cannot be made from our data, as they are cross-sectional; however, this result does suggest that older adults are the most susceptible to adverse neuropsychological outcomes in the context of HIV and binge drinking. Notably, this result also held when restricting the maximum age range to 60 years old for all groups, indicating that HIV/ Binge group differences in delayed recall and motor skills emerge even in the earlier stages of older adulthood.

It is possible that the response to experiencing of a positive violation of expectations compared to a non-violation of expectations is not reflected in the adult literature because adults are less sensitive to uncertainty in social contexts compared to adolescents . Thus, perhaps meeting social expectations in adolescence is [developmentally] a phenotypically unique phenomenon. Additionally, we suggest it may be likely that if adolescents receive unexpected positive feedback from an unknown peer compared to a known friend, it would result in self-reported happiness , as they would have fewer relationship priors on which to base their expectations. Notably, adolescents spend more time with known peers than unknown peers, so a task that manipulates statements from a known peer may elicit stronger and perhaps different behavioral and neural responses from an adolescent than if the statements were from someone the adolescent did not know well. We propose that tasks assessing responses to social expectations in adolescents should consider the nature of the relationship of the peer , as the response of the target may vary significantly based on prior knowledge of the relationship. Our neuroimaging results demonstrate that adolescents recruit more affective circuitry when processing social violations of expectations compared to nonsocial violations of expectations. This finding is consistent with literature suggesting greater subcortical recruitment in adolescents when they receive social compared to non-social feedback . Additionally,plant benches adolescents recruited the VS and insula differentially when they experienced positive compared to negative violations of expectations.

Positive social violations compared to social negative violations also yielded activation in the VS, insula, and subACC. While we did not find significant behavior associated with neural activation, we posit that the increased happiness participants reported for positive compared to negative social violations suggests participants were happier and recruited the VS when they experienced positive social violations of expectations. When they experienced negative social violations of expectations, they reported feeling less happy by comparison and recruited the subACC and the insula. These results highlight important associations in how adolescents report feeling and the neural regions recruited when they learn new social information from someone they care to receive social feedback from. Finally, participants who had been more accurate in their expectations of what their friend would report and what their friend reported in the Friendship Questionnaire, and who had fewer total differences between their expectations and their friend’s reported responses reported feeling happier after experiencing a positive violation of expectations. This result supports our hypothesis that friendship closeness or quality may account for the differences exhibited in behavior and self-report when participants experienced a violation of their expectation. Furthermore, adolescents who reported greater friendship duration were particularly happy when expectations were met, suggesting they may be more knowledgeable about their friendship and felt more relief knowing they were accurate in their expectations. This supports our rationale to include a friend as a peer in the study design—as this addition suggests response to a peer may be specific to the closeness of the relationship given that behavioral and neural responses between adolescents who were not as close were different by comparison.

While our study has notable strengths, we acknowledge a few caveats.Thus, it was more challenging to assess positive violations of expectations compared to negative violations of expectations. Future research in this area should consider how to increase values of positive social violations of expectations to test this effect more precisely. Additionally, we posit that responses to violations of expectations in a friendship of a wide range may encompass thought processes that a restricted range may avoid. Indeed, when we restrict our analyses to a range of VoE-4 to VoE+4 values of violations, we find significant differences in behavior as we predicted, and more robust differences in self-report and neural recruitment. However, we recognize that by restricting our analyses, we also limit the amount of statistical power associated with our questions, and remove any significant responses to violations that may lend themselves to future responses. Finally, we found few significant differences between social and non-social trials in our task, perhaps due to the limited number of non-social items. Future research should consider expanding on non-social items to further probe these differences. To our knowledge, the present study is the first to highlight differences in adolescent responses to social feedback from a friend based on valence and VoE value. Understanding these differences is important, as differential feedback has been known to influence behavior, especially in adolescence, as teenagers’ behaviors can be reflective of their diminished cognitive control in affective situations. Moreover, most adolescent peer interactions occur with friends, and adolescents are particularly keen on social acceptance. Thus, by incorporating “authentic” feedback participants are actually interested in outside of the laboratory, we can elucidate differences that may not otherwise appear had we used a confederate or virtual peer.

Learning new social information is critical during adolescence, as it is a time in development spent largely with friends. While research has determined receiving unexpected positive feedback results in more approach behaviors and receiving unexpected negative feedback results in more avoid behaviors , our study finds that receiving expected social feedback may result in greater approach behaviors, as it may be more reinforcing,gardening rack or rewarding than unexpected positive social feedback. We found that adolescents who are close friends prefer to learn they were correct in their expectations about their friendship, even if their friend reports something better than they expected; while adolescents who are not as close prefer to learn something better than expected and take longer to respond—perhaps indicating they are learning something new about someone they know only somewhat well. We suggest that learning unexpected social information at this age can be discordant with internal representations, which perhaps allows for it to be more easily remembered. However, we conclude that any new and unexpected social information garnered during this age about a close friendship may be disruptive to the cognitive harmony that a teenager has regarding his/her friendship, which may have implications for adolescent behavior in affective contexts. Adolescence marks a time of increased exploration and socialization with peers, where teenagers take risks more than other age groups, and often do so in the presence of their peers . While many of the risks they take lead to positive long-term outcomes , and finding a romantic partner, some can lead to negative outcomes, including health compromising behaviors such as getting into automobile accidents , and substance use . It has been proposed that a cascade of developmental changes in the brain during adolescence underlie these behaviors . As the brain develops during adolescence, there is a surge in dopamine in the limbic system coupled with a lack of functional connectivity with the prefrontal cortex . Thus, adolescents are more inclined to engage in reward-related activities, in part because they demonstrate diminished cognitive control and an increased neural response to reward . The same neural circuitry that is involved in reward processing also processes prediction error , defined as the neural computation of the difference between the expectation of an event and its actual outcome. PEs are positive or rewarding in nature when the actual outcome is better than the expected outcome and negative when the actual outcome in worse than the expected outcome. Our research is consistent with a large literature on PE in demonstrating that the neural circuitry implicated in reward PE —a region rich in dopamine receptors is also implicated in positive social violations of expectations , suggesting the neural processing of basic reward learning extends to the experience of positive social VoE in adolescence . While researchers have associated real-world behaviors with neural activation to reward PE in adults , none have determined whether an association exists between positive social VoE and real-world behaviors in adolescents. It is especially important to explore if the same processes are involved for basic reward and positive social processing in adolescents, as we may expect adolescents who demonstrate enhanced engagement of these processes to partake in more rewarding activities. Many adolescents in the United States have had social experiences in which they have been offered or have used licit/illicit substances as risky). Research indicates that nationwide, 18.1% of adolescents have had alcohol prior to age 13, and 34.9% have had a drink at least once in the past month .

Alcohol and drug induced deaths are one of the most avoidable causes of accident and death in the United States . Like most risk taking behaviors, adolescents are more likely to use substances with their peers or in social settings , suggesting that substance use in adolescence is a social behavior. Additionally, the types of substances adolescents use varies greatly, though most commonly, adolescents tend to use alcohol and tobacco and are least likely to use heroin —as the former is perceived as having fewer severe consequences and is more socially acceptable.Recently, researchers have associated the basic reward processes involved in PE to vulnerability to substance addiction in adults , though none have associated response to VoE with self-reported substance use in adolescents. The goal of this study was to elucidate the relation between the rewarding experience of learning social information from a friend to self-reported risky and rewarding social behaviors in adolescents with the aim of identifying whether the ventral striatum activation evinced in social VoE is associated with the extent to which adolescents use substances. Because previous research has demonstrated a positive association between ventral striatal response to reward PE in adults and their substance use behaviors, we hypothesize adolescents who demonstrate greater ventral striatal activation in response to positive social violations of expectations will also report greater and more frequent use of substances than those who demonstrate decreased VS recruitment. Twenty-six participants completed the initial fMRI study that assessed behavioral and neurobiological responses to social violations of expectations. Nineteen adolescents were re-enrolled in the behavioral follow-up study ; primary reason for subject attrition was college attendance out of state. The average amount of time that elapsed from participation in the first study to the second was 613.11 days . The participant group was ethnically diverse , and did not differ by socioeconomic status— measured as average level of parental education obtained in the household = 6.22, p = .62.Target participants completed self-report surveys that assessed their friendship status with the friend that completed Study 1 with them; rejection sensitivity ; resistance to peer influence ; and risk taking and substance use behaviors , ; Ontario Student Drug Use and Health Survey , . Friendship status questions asked participants how close they remembered being friends with the friend who accompanied them at Study 1, and how close they were at Study 2. Participants responded on a Likert scale from 1 to 5 . A Friendship Difference Score was calculated by subtracting the friendship status score reported from Study 1 from the friendship status score reported from Study 2 to determine whether participants were closer or less-close between Study 1 and Study 2. Items from the RSQ first asked participants how concerned or anxious they would be about someone’s response to a question ; followed by asking them how they thought a person would respond on a scale of 1 to 6 . Participants responded to 18 pairs of questions prior to proceeding to the OSDUHS. Items from the OSDUHS asked participants about their demographic information and behavioral information . Items pertaining to their substance use requested history of use, frequency of use in the past 12 months, frequency of use in the past 4 weeks, and how usage impacted daily life. Participants responded by selecting an answer that best corresponded to their habits. A sample item read, “In the last 12 months, how often did you use cannabis ?” Participants responded by selecting one of the following: “1 or 2 times; 3-5 times; 6-9 times; 10-19 times; 20-39 times; 40 or more times; used but not in the last 12 months; never used in lifetime; don’t know what cannabis is.” Items pertaining to their risk taking behavior asked about activities they participated in while they or a peer was under the influence.

In agreement with this idea, recent electrophysiological experiments have suggested that endocannabinoid compounds may serve as retrograde messengers in both hippocampus and cerebel- Ž lum Kreitzer and Regerh, 2001; Ohno-Shosaku et al., . 2001; Wilson and Nicoll, 2001 . Finally, the finding that anandamide and 2-arachidonylglycerol may be produced through divergent molecular mechanisms indicates that these two endocannabinoid lipids may exert their modulatory effects in separate and possibly complementary ways.Drugs that interfere with anandamide transport have both theoretical and practical interest. Theoretically, they may help uncover the functions of the endocannabinoid system, which remain largely uncharacterized. Practically, they may find applications in a range of therapeutic areas, such as pain, multiple sclerosis and motor disorders ŽPiomelli et al., 2000; Baker et al., 2000; Giuffrida et al., . 2000a . AM404—the first synthetic inhibitor of anandamide Ž . uptake Beltramo et al., 1997 —has been shown to poten- Ž tiate many effects elicited by anandamide in vitro Be- . Ž ltramo et al., 1997 and in vivo Beltramo et al., 1997; . Calignano et al., 1997a . Because of the inability of AM404 Ž to activate cannabinoid receptors Beltramo et al., 1997, . 2000 , the effects of this drug were suggested to result from the elevation of endogenous anandamide levels. However, this hypothesis was solely based on pharmacological evidence and was not supported by direct measurements of endogenous anandamide levels after AM404 administration. In the present study,pruning cannabis we show that systemic administration of AM404 causes an increase in the concentration of circulating anandamide.

This was accompanied by an elevation of AM404 levels in plasma, which reached a peak value of 123″22 pmolrml and remained as high as 70.5 pmolrml for at least 2 h after drug administration. These values are likely to reflect the amount of AM404 bound to plasma proteins. Indeed, we found that both AM404 and anandamide bind to a protein in plasma, which we identified as albumin by non-denaturing PAGE.The concentrations of AM404 at its sites of action, i.e., at the membranes of cells expressing the putative anandamide transporter, remain at present undetermined. To further investigate the biochemical effects of AM404 in vivo, we also monitored the plasma levels of palmitylethanolamide and oleylethanolamide, two fatty acylethanolamides that are produced through the same biosynthetic Ž mechanism of anandamide Di Marzo et al., 1994; Cadas . et al., 1997 , but do not serve as substrates for the anan- Ž . damide transporter Piomelli et al. 1999 . AM404 administration did not significantly affect the levels of palmitylethanolamide, but caused a slow increase of circulating oleylethanolamide statistically significant 120 min after AM404 injection. Since oleylethanolamide is not transported by anandamide carrier, a possible interpretation of this result is that AM404 may inhibit an as-yet uncharacterized transporter of oleylethanolamide. Alternatively, oleylethanolamide elevation may result from the interference of AM404 with anandamide amidohydrolase, of which oleylethanolamide represents a substrate. However, administration of the potent anandamide amidohydrolase blocker, Ž .Ž . palmitylsulfonyl fluoride AM374 Gifford et al., 1999 had no effect on circulating anandamide levels, although it significantly increased the levels of oleylethanolamide 30 Ž min after drug application A. Giuffrida, F. Nava, A. . Makriyannis and D. Piomelli, in preparation . Taken together, these results suggest that blockade of anandamide amidohydrolase activity is unlikely to participate in the elevation of anandamide in plasma, but may cause the accumulation of other fatty acid acylethanolamides.

In parallel with its ability to increase anandamide levels in plasma, AM404 also elicited a time-dependent inhibition of motor activity. The hypokinetic effect of AM404 is reminiscent of that observed after anandamide administra- Ž tion Fride and Mechoulam, 1993; Smith et al., 1994; . Romero et al., 1995 and was reversed by the cannabinoid CB receptor antagonist SR141716A. This drug prevents 1 Ž several responses of anandamide in rats Calignano et al., . Ž 1998 , mice Beltramo et al., 1997; Calignano et al., .Ž . 1997b and guinea pigs Calignano et al., 1997a . However, failure of SR141716A to reverse anandamide actions Ž . was also reported Adams et al., 1998 . The reason for these discrepancies are unresolved, and may be due to differences in species, dosage of the drug and experimental design. Since the motor inhibition produced by AM404 was achieved at a dose that also caused accumulation of anandamide in peripheral blood, and given the inability of Ž AM404 to activate cannabinoid receptors Beltramo et al., . 1997, 2000 , our results are consistent with the hypothesis that AM404 produced its behavioral effects by protecting endogenous anandamide from transport-mediated inactivation. Alternatively, the effects of AM404 may be ascribed to its ability to activate vanilloid VR1-type receptors ŽZygmunt et al., 2000; Smart and Jerman, 2000; Jerman et . Ž. al., 2000 . This possibility is unlikely for two reasons: 1 the effects of AM404 were prevented by the highly selective cannabinoid CB receptor antagonist, SR141716A, 1 which does not interfere with vanilloid VR1 receptor Ž . Ž. function Calignano et al., 2000 ; 2 injection of vanilloid agonists into the brain does not cause hypolocomotion Ž . Mezey et al., 2000 , the primary effect of AM404 ob- Ž served in the present and other studies Beltramo et al., . 2000; Gonzalez et al., 1999 . ´ Although the concentrations reached by anandamide in Ž . plasma approximately 10 nM are insufficient to activate cannabinoid receptors ŽK s50 nM and 1.6 mM for CB d 1 .Ž . and CB receptor, respectively Pertwee, 1997 , it is 2 reasonable to hypothesize that AM404 may cause anandamide to accumulate in brain tissue to an extent that is sufficient to cause biological effects. This would explain why the motor inhibition elicited by AM404 takes place before significant accumulation of anandamide in plasma is observed.

However, the sources of plasma anandamide following AM404 administration are still unknown. Indeed, anandamide production has been demonstrated not only within the central nervous system, but also in periph- Ž eral cells, such as macrophages and platelets Schmid et . al., 1997; Wagner et al., 1997 . Microdialysis studies aimed at measuring anandamide outflow in brain areas involved in motor control after AM404 administration should shed light in this important question.Heart failure is the fourth overall principal diagnosis and first among cardiovascular conditions as the reason for hospitalization in the U.S.Heart failure is a prevalent condition with several preventable etiologies including uncontrolled hypertension or ischemic heart disease.Behavioral risk factors such as tobacco, alcohol, and drug use are known to contribute to heart failure incidence.Alcohol, cocaine, and amphetamines have cardiotoxic effects. Drug overdose death rates in the U.S. are rising, especially in younger persons.The burden of active tobacco and substance use disorders among hospitalized heart failure patients in the U.S. has not been well described. Nationally representative administrative data facilitates understanding the burden of tobacco and substance use disorders among heart failure patients and its potential influence on health outcomes. Vulnerable populations,drying room including patients from racial/ethnic minorities or lower socioeconomic status, may be at increased risk of developing tobacco or substance use disorders for multiple reasons including social stressors, lack of economic opportunity, and community factors.Identifying heart failure patients with tobacco or substance use disorders is critical to developing treatment strategies to address observed cardiovascular health disparities. We describe the national burden of heart failure and comorbid tobacco or substance use disorder among hospitalized patients in the U.S. We used data from the 2014 National Inpatient Sample to describe diagnosis rates of tobacco and substance use disorders among hospitalized heart failure patients and examined demographic groups that may be at higher risk for these disorders.The NIS dataset provides hospital administrative data through the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project. It contains approximately 7 million weighted hospital discharges representing 35 million inpatient hospitalizations.The NIS unit of analysis is a discharge; therefore, readmissions are not identified. The sample is drawn from forty-four states and the District of Columbia, covering more than 96% of the U.S. population. A 20% stratified sample is obtained from 4,411 U.S. community hospitals. All insurance payer sources are included.Heart failure was defined by any International Classification of Diseases, Ninth Revision Clinical Modification code that mentioned a heart failure syndrome . A primary heart failure hospitalization was defined as any heart failure ICD-9-CM code used as the first listed discharge code, consistent with prior publications.Patients less than 18 years were excluded. Race/ethnicity was classified as white, black, Hispanic, Asian/Pacific Islander , or Native American as captured by administrative hospital data. Additional demographic factors included age, sex, payer source, geographic Census division, and median household income based on zip code. Substance use disorder was defined as any alcohol or drug use disorder, excluding tobacco, which was a separate outcome. Tobacco, alcohol, and drug use disorders were defined using Clinical Classifications Software and ICD-9-CM codes .Drug use disorder was sub-divided into cocaine, cannabis, opioid, amphetamine, psychotherapeutic , hallucinogen, and other use disorder categories.

Overall and for each tobacco and substance use disorder category, we estimated the national proportion of hospitalized heart failure patients and provided descriptive statistics for patient characteristics, select comorbidities, hospital length of stay, and inpatient mortality. We next stratified heart failure hospitalizations by sex and other demographic factors . For each stratum, we reported the percent of patients in each tobacco or substance use disorder category. Tobacco and substance use disorder rates were age-standardized using the 2000 US Standard Population, per Center for Disease Control and Prevention recommendations.To evaluate demographic factors associated with each comorbid tobacco or substance use disorder category, we used logistic regression models accounting for clustering and non-linear age-adjustment using multi-variable fractional polynomials.Selection of best-fit multivariable fractional polynomial models used a closed-test algorithm.This curvilinear adjustment was used to reduce residual confounding that may arise secondary to model misspecification using age as a single linear term.All estimation procedures were performed with appropriate NIS survey weights to account for sampling design, and all results are presented as the weighted national 2014hospitalized population. Analyses were performed in STATA 15.1 . Institutional IRB provided an exemption for this research.There were 989,080 heart failure hospitalizations in the U.S. in 2014 of which 15.5% had documented tobacco or substance use disorder. Tobacco use disorder was found in 12.1% , substance use disorder in 6.2% , alcohol use disorder in 3.5 % and drug use disorder in 3.5% . Both tobacco and substance use disorder were documented on 2.8% of heart failure hospitalizations, while both alcohol and drug use disorder were found in 0.7% . In the overall heart failure cohort, mean patient age was 72.0 , and females comprised almost half of the hospitalizations. The majority of heart failure hospitalizations were for patients age 65 or older , of white race/ethnicity , and with payer source of Medicare . The most common comorbidities were hypertension and coronary artery disease . Demographic patterns of the cohort with no tobacco or substance use disorder mirrored that of the overall heart failure cohort. Tobacco use disorder patients were younger than the overall heart failure cohort and 36.0% female. Tobacco use disorder was more common among males than females across demographic subcategories . Rates were highest for both sexes between ages 45 and 55 . Native American males had highest age-adjusted rates , while white and Native American females had highest age adjusted rates . Tobacco use disorder rates were highest in the East South Central region and for payer status of no charge , self-pay , or Medicaid . Rates of tobacco use disorder increased as median household income decreased. Heart failure hospitalizations with documented substance use disorder represented younger patients than the overall or tobacco use disorder cohorts and were 22.9% female . Substance use disorder diagnosis rates were highest for males 45 to 55 years of age and females <45 years of age . Native Americans had highest rates of substance use disorder when age-adjusted . Substance use disorder was highest for heart failure hospitalizations in the Pacific region, payer status of Medicaid, self-pay or no-charge, and for lower income quartiles. Alcohol use disorder was less common among female heart failure hospitalizations relative to tobacco and drug use disorder . Heart failure hospitalizations for those age 45 to 55 years had highest rates of alcohol use disorder .

All participants provided written informed consent prior to study participation. Participants were included in the analyses if they maintained at least one current prescription for an antiretroviral medication and completed an approximately month-long observation of adherence using Medication Event Monitoring System . Based on a parent project , exclusion from the study occurred if a participant had a severe psychiatric disorder , major neurological disease , estimated verbal IQ < 70 determined using the Wechsler Test of Adult Reading , diagnosis of a current substance use disorder at baseline, positive urine toxicology screen for illicit substances at baseline. Adherence was tracked using MEMS, which utilizes a microchip-containing bottle cap that records the time, date, and frequency with which the bottle is opened. All participants were provided the MEMS bottle the day of neuropsychological testing and continued use for approximately 5 weeks . Participants were asked to use only the bottle provided to dispense their medication, to open the bottle only for the purpose of dispensing their medication, and to dispense only one dose of medication at a time. The ARV selected for the MEMS bottle was based on whether the participant would continue the medication through the course of the study, the frequency with which the medication is prescribed in the general population ,cannabis dryer and its pharmacokinetic properties. Blind reviewers used the MEMS data to categorize participants as either adherent or non-adherent. Participants were determined adherent if they followed their target antiretroviral prescription regimen ≥ 90% of the time.

Table 1 displays descriptive data for non-cognitive variables that differed between the Adherent and Non-Adherent groups. There were no significant between group differences in demographics , HIV disease characteristics , or medication regimen complexity . The Adherence groups were also comparable on most psychiatric characteristics, including current Major Depressive Disorder , current and lifetime Generalized Anxiety Disorder , current mood as measured by the Profile of Mood States , lifetime substance dependence, and positive urine toxicology screen for cannabis on the day of testing . Because a positive marijuana urine toxicology screen was allowed on the day of testing, between-group differences were evaluated to determine the potential confound of acute cannabis effects on adherence. No significant differences were found between adherent and non-adherent participants or between the normal , encoding deficit , and retrieval deficit algorithm-derived clinical classification profiles . There was a significantly higher prevalence of lifetime MDD in the Non-Adherent group; however, this variable was not associated with any of the primary memory variables of interest in the entire study cohort , with the sole exception of CVLT-II Total Trials 1-5 . Follow-up logistic regressions showed that LT MDD did not affect the magnitude of the association between CVLT Total Trials 1-5 and adherence . Moreover, CVLT-II Total Trials 1-5 was not associated with current depression or the depression/dejection subscale of the Profile of Mood States . As such, we did not include LT MDD as a covariate in any of our subsequent analyses.

The CVLT-II includes 16 nouns across four semantic categories that are read aloud to the participant, who is asked to recall as many words as possible. After 5 identical learning trials, a new list of 16 nouns is presented to the participant for recall. Immediately following the distractor list recall, the participant is asked to recall the original list without and with semantic prompts. After a 20- minute delay, the participant is again asked to recall the words from the original list without and with semantic prompts. A yes/no recognition trial is then administered in which participants are read a list of words that includes both targets and distractors . Participants were also grouped into three CVLT-II deficit profile classifications: encoding deficit , retrieval deficit , and normal profile . These profile classifications apply a previously published algorithm to identify which deficit is more prominent within an individual’s profile of memory dysfunction. Massman and colleagues developed this algorithm by first identifying the indices that had the highest likelihood of differentiating prototypical cortical from subcortical dementias. These three indices included the standard scores from the total recall across all learning trials , a standard score for the number of intrusions on two cued recall trials, and a difference score between the standard recognition discriminability score and free recall on the final CVLT-II learning trial. In the WMS-III Logical Memory I and II subtests , participants are presented two narrative paragraphs read aloud by the examiner, which they are asked to recall immediately following the presentation of each paragraph . Procedures for story B immediate recall are completed twice.

After a 30- minute delay , participants are again requested to recall the information from each story. Recognition is tested immediately following the delayed recall trial with a forcedchoice trial. The LM-I total score is derived from story A and both story B immediate free recall trials. The percent of information retained is derived by comparing the information recalled between the immediate and delayed recall conditions. Medication non-adherence is common in HIV disease, particularly among individuals with memory deficits . The current study extends our understanding of the memory profile associated with cART non-adherence. Consistent with earlier studies on this topic, our data showed that episodic verbal learning and memory have broadly medium associations with adherence in HIV+ individuals, with CVLT-II surprisingly showing smaller average effects than WMS-III LM . The profile of memory findings in the non-adherent cohort was characterized by deficits in initial acquisition and delayed free recall, but not in retention or recognition. This pattern of findings is consistent with what has been described as a “retrieval” deficit, which is commonly found in persons with HAND and other conditions that affect prefronto-striato-thalamo-cortical circuits . Of note, algorithm-derived clinical classifications of the CVLT-II showed that HIV+ non-adherers have a higher prevalence of subcortical retrieval deficit profiles and that those with such retrieval profiles were three times more likely to be non-adherent than those with an encoding deficit profile. This is interpretively consistent with the work of Wright and colleagues , who found that non-adherent HIV+ persons differed from healthy adults on the ISDA index of retrieval, but extends that prior paper by: using traditional CVLT-II indices that include retention and recognition; incorporating a measure of passage recall, providing classifications of individual profiles using the algorithm-derived methods of Massman and colleagues along with traditional CVLT scoring methods and demonstrating associations between the algorithm profile approach and ecologically relevant measures of everyday functioning. The significant associations between adherence and profile scores in the context of insignificant standard deficit scores underscores the clinical relevance of understanding individual profiles of memory deficits when evaluating everyday functioning outcomes. Future research comparing this algorithm across HIV and other well-established cortical and subcortical deficits using both neuropsychological and ecologically valid real world tests appears warranted to better understand the true impact of these deficit profiles across disorders. From a memory process perspective,cannabis curing these findings indicate that missing a medication dose is not simply a “forgetting” problem , as there was no evidence of an association between adherence and memory savings scores or recognition performance. Instead, non-adherence in HIV is at least partly associated with deficits in the complex process of efficiently accessing information from episodic verbal memory with minimal retrieval cues. Such retrieval deficits may be a function of weak encoding and/or difficulties with self-initiated memory search and access to stored information. Therefore, even if an HIV+ individual understands and encodes the relevant information regarding their cART regimen, he/she may still not remember to take his/her medication as prescribed at least in part due to difficulties retrieving the proper information at the later dosing time. These memory processes did not appear to change depending on the complexity of one’s regimen, instead, difficulty retrieving information was associated with non-adherence regardless of the number of pills an individual was prescribed. Importantly, these complex memory process failures may also occur in concert with failures in other aspects of cognition , psychiatric comorbidities, and various psychosocial factors , which may further complicate and exacerbate the observed retrieval deficits.

Indeed, there are numerous neurobehavioral aspects involved in managing one’s medication regimen . The absence of an association between executive functions and adherence may at first appear contrary to the known pattern of deficits seen in individuals with fronto-striatal dysregulation, such as in HIV disease. Indeed, prior studies have shown that executive functions are related to cART non-adherence . However, the free recall memory variables that differentiated the adherence groups were associated with executive functions in the non-adherence group, which supports the hypothesis that a deficiency in the higher-order, organizational aspects of memory processes may play an important role in medication non-adherence. Specifically, Moscovitch described a component process theory that included a higher-order control process by which the frontal systems work “with” encoding and retrieval to properly organize information for efficient storage and recall. Poor strategic encoding and retrieval has been observed in HIVseropositive individuals , and therefore the profile of deficits and the observed associations with executive dysfunction findings suggest that these strategically driven aspects of memory processes are important for successful medication adherence in HIV. The stronger association between non-adherence and story recall versus list learning was surprising, as we had expected the purported executive demands of list learning to be more important in the context of managing medications . However, this unexpected finding may reflect the relevance of contextual information to understanding memory’s effects on important aspects of everyday functioning, such as medication adherence. In other words, the stronger associations between story memory and adherence underscores the importance of an individual’s ability to understand and independently recall medication information presented in a contextual format for proper regimen adherence. There is a long history of episodic memory research on the role of context in facilitating recall and the match between the context of encoding and retrieval . In this instance, therefore, story recall may better match the everyday demands of memory on adherence than does list learning. Non-adherers may have greater difficulty remembering and applying regimen information presented conversationally by their healthcare providers and in the context of related information as opposed to being presented with a listed dosing schedule. This provides one explanation for why the LM subtest has historically provided a more sensitive test for subtle memory deficits compared to the CVLT . Morgan and colleagues , to this end, demonstrated that individuals with HAND evidenced difficulty with contextually-based health information. Specifically, the HAND group performed more poorly on an applied task in which health-related information was provided in the full context of a detailed scenario involving a health choice . This finding is consistent with the results of the present study, suggesting that medication regimen instructions presented in the larger context of health-related information may interfere with, rather than facilitate, memory for that information and subsequently decrease adherence. These findings suggest that when complex, contextualized health information is provided to patients it should be supplemented with more focused, targeted instructions that facilitate adherence to the prescribed health plan. Several limitations of this study are important to highlight. This study focused exclusively on verbal episodic memory. Due to a heavy reliance on reading prescription labels to obtain medication regimen information as well as visual cues when dispensing and dosing medications , understanding memory profiles associated with visual stimuli could also be of value. Because MEMS caps were utilized for adherence observations, the effects of commonly used compensatory behaviors, such as using pillbox dispensers , on adherence were not evaluated, therefore reducing some generalizability to everyday life. Further, future studies could improve our understanding of these profiles on medication non-adherence by evaluating the efficacy of commonly used compensatory strategies among individuals with specific profiles of memory deficits. This study also examined memory associated with common words and simple stories. However, drug labels often include complex medical and numeric information , which may influence adherence. Multiple studies found that retention of medical information has been as low as 25% . Therefore, it would be more ecologically relevant to examine memory in the context of medical information and complex descriptions rather than the commonly understood information presented on the clinical memory tasks used in this study.

Gender differences have been noted in the neuropharmacological actions of nicotine , such that P4 and E2 have been associated with the rewarding effects of nicotine , with E2 regulating nicotine-induced release of dopamine . A recent meta-analysis by Weinberger and colleagues suggested that the luteal phase of the menstrual cycle, a time in which P4 and E2 levels are elevated, is associated with greater nicotine withdrawal and moderately higher craving than the follicular phase, a time of low P4 levels. Severity of pre-menstrual symptoms, often occurring towards the end of the luteal phase when E2 and P4 levels are elevated, is associated with smoking behavior, nicotine withdrawal, and relapse . These results suggest that sex hormone levels, as a function of menstrual cycle phase, may affect smoking related behaviors and ability to quit smoking. Sex differences have also been examined in response to opioid receptor antagonists such as naltrexone. Naltrexone has been shown to produce greater nicotine withdrawal and ACTH and cortisol levels in women than men . Menstrual cycle phase and sex hormone levels have been shown to affect responses to naltrexone . A previous study enrolled 70 subjects in a double-blind, placebo-controlled human laboratory study in which men and women completed two sessions where they received either 50 mg oral naltrexone or placebo in a randomized, counterbalanced order. Women were randomized to complete both sessions in either the early follicular or luteal phase of their menstrual cycle. Due to the change in sex hormone levels across the menstrual cycle,cannabis hydroponic set up the early follicular and luteal phases of the menstrual cycle allowed for a comparison of high and low E2 and P4 levels.

Hormone measurements of E2, P4, follicle stimulating hormone , and luteinizing hormone were used to confirm menstrual cycle phase. In luteal women, but not early follicular women or men, naltrexone increased salivary cortisol from baseline compared with placebo . Naltrexone significantly increased serum cortisol and prolactin in both early follicular and luteal women, but not men. Of note, luteal women’s serum cortisol and prolactin responses to naltrexone were significantly greater than those of both men and early follicular women. In luteal women, but not in men and early follicular women, In luteal women, but not early follicular women or men, naltrexone increased salivary cortisol from baseline compared with placebo . Naltrexone significantly increased serum cortisol and prolactin in both early follicular and luteal women, but not men. Of note, luteal women’s serum cortisol and prolactin responses to naltrexone were significantly greater than those of both men and early follicular women. In luteal women, but not in men and early follicular women,naltrexone increased the severity of adverse effects from baseline . These results suggest that women in the luteal phase of the menstrual cycle, most likely due to high P4 and E2 levels, are more sensitive to the effects of naltrexone compared to men and early follicular women with low P4 and E2 levels. The increased negative health consequences and worse smoking cessation outcomes provide clear evidence for the necessity of finding smoking cessation medications that are effective among women. Chapter 2 of the dissertation examined the effects of sex hormones on smoking and drinking outcomes among premenopausal women during a randomized controlled trial for smoking cessation and drinking reduction. This chapter is currently published in Alcohol and Alcoholism. Cigarette smoking remains a leading preventable cause of morbidity and mortality. Sex differences in cigarette smoking and smoking cessation rates have been noted. The 2019 National Health Interview Survey found 14% of U.S. adults reported current cigarette smoking; of that, 15.3% were men and 12.7% were women .

While men are more likely to smoke than women , women may be at greater risk for worse health consequences, have greater difficulty quitting, and often have less success in smoking cessation trials . It is therefore essential that sex be examined in smoking cessation treatment. While pharmacological treatments are available to aid in smoking cessation and drinking reduction, their efficacy is moderate. Varenicline is a first-line treatment for smoking cessation that has shown benefit on drinking outcomes as well . Several studies have found that the effects of varenicline on smoking outcomes may be sex dependent. A meta-analysis by McKee and colleagues found that in comparison to men, varenicline was more effective among female smokers for short and immediate smoking cessation outcomes but was equally efficacious for longer term outcomes. These findings are promising, however in contrast to the aforementioned findings of women experiencing worse outcomes in smoking cessation trials. Naltrexone has a robust literature for drinking outcomes and has also been used in a host of smoking cessation trials in heavy drinking smokers with mixed results . Studies of sex effects have also considered the role of menstrual cycle hormones on smoking and drinking behaviors. At the onset of menses and throughout the follicular phase of the menstrual cycle, progesterone remains low. After ovulation, P4 rises to its peak level by mid-luteal phase and gradually declines before the next menses. Conversely, estradiol is lowest during menses, rises throughout the follicular phase, peaks at ovulation, and then reaches a secondary peak during the luteal phase before again declining. In comparison to the luteal phase, women randomized to quit smoking in the follicular phase exhibited worse cessation outcomes as shown by fewer days to relapse from continuous abstinence and prolonged abstinence . When examining hormone values directly, P4 has been shown to be protective in reducing smoking by decreasing the rewarding aspects of smoking, while E2 may increase smoking through increasing smoking reward .

An observational study in non-treatment seeking smokers revealed that higher within-subject levels of P4 were associated with reduced cigarettes per day, however there was no effect of estradiol on cigarettes per day . Furthermore, exogenous progesterone has also been shown to promote smoking cessation among women . Specific to alcohol use, P4 and E2 have also been shown to have a distinct association with alcohol use. Alcohol consumption, both in a naturalistic environment and in a controlled experimental condition, has been associated with reductions in P4 . Greater endogenous E2 was associated with an increased likelihood of drinking and binge drinking on weekend days, and these effects were the strongest in the context of low P4 . The effect of hormone levels on alcohol consumption may also be dependent on mood: women were more likely to consume alcohol on days when their progesterone levels were low and they were experiencing greater negative mood than their typical mood state . Conversely, when women were experiencing an increase in progesterone, they were more likely to consume alcohol on days when they reported a positive mood . Relative to smoking cessation, fewer studies have examined the impact of P4 or E2 on alcohol reduction or abstinence outcomes. Collectively, these studies suggest the potential for P4 to serve as a protective factor, and E2 a risk factor, for both smoking behavior and alcohol use. In addition to examining P4 and E2 separately, past studies have examined the ratio of P4 to E2 in relation to cigarette use . Schiller and colleagues examined how ratios of P4/E2 and E2/P4 may alter smoking topography in a sample of female cigarette smokers. They found the ratio of P4/E2 was more strongly correlated with smoking behavior than the ratio of E2/P4 . Lastly,hydroponic system for cannabis there is evidence to suggest that pharmacotherapy may alter crucial hormone levels that could impact smoking behaviors. A prior examination of brief pharmacotherapy for smoking cessation found an increase in progesterone levels following treatment with varenicline and nicotine replacement therapy; of note, this effect was predominantly driven by those randomized to the nicotine replacement therapy group . Interestingly, there is also evidence that the acute effects of naltrexone may be sex-dependent with regard to menstrual cycle phase. Roche and King found that in response to an acute dose of naltrexone, women in the luteal phase exhibited greater cortisol and prolactin responses, and reported greater severity of adverse effects, in comparison to women in the follicular phase and men. Taken together, the literature suggests that both varenicline and naltrexone have sexdependent effects that may be best captured mechanistically through assessing menstrual cycle hormones. Ray and colleagues conducted a randomized controlled trial for smoking cessation and drinking reduction. Participants were assigned to receive either varenicline plus placebo or varenicline plus naltrexone for 12 weeks, with follow-up appointments conductedat week-12 and week-26. The results from this randomized clinical trial by Ray and colleagues found participants randomized to the varenicline plus placebo condition reported greater smoking cessation at week-26. For alcohol use outcomes, there was some benefit of the combined varenicline plus naltrexone for reducing drinks per drinking day however it did not meet statistical significance .

This study highlights the potential benefits of combined pharmacotherapy for predominantly alcohol use outcomes among heavy drinking smokers. The present study is an exploratory secondary analysis of Ray and colleagues , supported by an NIH supplement to investigate sex-differences. At weeks 4, 8, and 12 postrandomization and during the active medication phase, participants provided saliva samples for assays of P4 and E2. The present study examines the effects of the ratio of P4/E2 during the active medication phase as predictors of smoking and drinking behaviors. The present study was an exploratory secondary data analysis to examine the effects of menstrual cycle hormones among premenopausal women on smoking and drinking outcomes during a clinical trial testing varenicline and naltrexone for smoking cessation and drinking reduction. The parent study for this secondary analysis found a benefit of combined varenicline and naltrexone for drinking outcomes, however not for smoking outcomes . Given previous work suggesting women in the luteal phase may be more sensitive to the effects of naltrexone , we were particularly interested in examining whether there was an interaction between medication and sex hormones. For smoking abstinence, we found no interaction effect between medication and ratio of P4/E2 or lower-order simple effect of P4/E2. There was a significant effect of medication in favor of those in the varenicline plus placebo condition experiencing greater smoking abstinence. This aligns with the results of the larger clinical trial . For the drinking outcome percent days abstinent, there was a significant interaction between medication and the ratio of P4/E2. In comparison to varenicline plus placebo, greater P4/E2 ratio was associated with greater percent days abstinent for those in the varenicline plus naltrexone condition. Since we expect to see higher P4/E2 ratio during the luteal phase, our results imply that during the luteal phase, participants in the combined varenicline plus naltrexone exhibited improvements in their drinking behavior as indexed by greater percent days abstinent in the 28- days leading up to the study visit. It is also possible that women who had relatively higher P4 and/or lower E2 during their luteal phase are more likely to be responsive to naltrexone. These results align with the findings of Roche and King in which women in the luteal phase were more sensitive to the acute hormonal effects and subjective effects of naltrexone, notably with increases in cortisol and severity of adverse effects in the luteal phase. Our results suggest that during a time when the ratio of P4/E2 is high, as we would expect in the luteal phase, women may experience an added benefit of naltrexone compared to when P4/E2 ratios are low, as we would expect in the follicular phase. It may be that the luteal phase is a time when women are more responsive to both the positive and negative effects of naltrexone. However, this finding should be viewed with caution, as there were no significant interactive or lower-order simple effects for the remaining drinking outcomes. The larger study from where these data was culled showed that the largest reduction in drinks per drinking day occurred from baseline to follow-up week 4, with notably smaller changes from week 4 through week 12 .Previous studies have shown an effect of P4 and E2 on smoking outcomes, independent of each other and as a ratio of P4/E2 . However, our results did not show an effect of lower or higher P4/E2 ratios on smoking abstinence and cigarette per day during the trial. It is possible that our sample did not have large enough variation in menstrual cycle phase across the three study visits.

As hypothesized, for both e-cigarettes and moist snuff smokeless tobacco, flavored products were viewed with more curiosity and as being less dangerous, less potent and easier to use compared to non-flavored products. Associations of flavors with greater curiosity and ease of use and less perceived danger held for all non-tobacco flavors, including mint and wintergreen. Thus, evidence from this cross sectional study population suggests that mint varieties should be included alongside fruit and dessert in flavor restrictions intended to reduce youth tobacco use. Other product characteristics, such as e-cigarette device type, vapor amount and moist snuff price, also appear to shape product perceptions, which could inform tobacco control policy. In January 2020, citing concern over growing youth e-cigarette use, the FDA announced a policy to prioritize enforcement of premarket authorization requirements for some types of e-cigarettes, but exempted mint and menthol flavors. The present results suggest that youth perceive the properties of mint and wintergreen flavored tobacco similarly to fruit, dessert, and other flavors, which could undermine the effectiveness of the FDA policy. No such enforcement policy exists for conventional smokeless tobacco, but the present results demonstrate similar flavor association for moist snuff as observed for e-cigarettes. This finding is consistent with tobacco industry documents suggesting that flavored, lower priced,cannabis grow indoor lower nicotine ‘starter products’ are used to target novice users before later ‘graduation’ to established use through a series of higher nicotine products.

Use of flavored tobacco, including menthol, is more common among youth than adults and is the predominant way youth and young adults consumed tobacco across all tobacco products. A review of qualitative studies reported that flavored tobacco is viewed favorably by consumers, who associate flavors with less danger and often report that flavors contributed to their own tobacco experimentation and initiation. Given the evidence that flavors contribute to youth use for all tobacco products, current policies should consider not only restricting all non-tobacco flavors in cigarettes and e-cigarettes but in all forms of tobacco. Pod-type e-cigarettes, such as market-leading brand JUUL, have become the most popular type of e-cigarette among US youth. Independent of nicotine content and flavor, participants in the present study viewed pod devices with more curiosity and as easier to use than other device types but not necessarily as less dangerous. However, participants also associated low nicotine content e-cigarettes with less danger, more curiosity, and greater ease of use. Research suggests that youth may not recognize that pod-type e-cigarettes contain nicotine at high concentrations; a misperception potentially reinforced by the nicotine amount printed on JUUL product packaging. Prior applications of discrete choice methods in tobacco control have focused on adults and/or recruited participants through online panels. Previously reported findings include a preference for non-tobacco flavors both in e-cigarettes and water pipe tobacco, as well as identifying warning labels as a factor reducing product interest. Consistent with the present study, Shang et al.reported that adolescents least prefer tobacco-flavored e-cigarettes and cigalike closed-system devices. The present study expands such work to moist snuff products, finds e-cigarette vapor cloud size and pod type devices as independent contributors to youth perceptions, and assesses the additional outcomes of perceived danger and ease of use.

Furthermore, the present study shows no gender difference regarding e-cigarette perceptions, although beliefs associated with certain moist snuff product attributes were stronger among male participants, likely reflecting higher use and male-targeted marketing. Not all perceived qualities observed in the present study aligned with actual product properties. Participants correctly associated higher nicotine content with stronger physical effects . Other perceptions, such as flavored tobacco or small vapor cloud e-cigarettes being less dangerous, are not supported by scientific consensus. This discordance between perceived and actual effects represents a possible area for corrective public messaging or for greater regulatory vigilance for potentially misleading marketing practices. Of note, and not unexpectedly, product ever users held stronger perceptions about device type and brands than did product naïve participants. In a cross sectional setting, it cannot be distinguished to what extent experience shaped perceptions or that existing attention to product attributes contributed to use initiation. The designations curiosity, danger and ease-of-use are open to subjective interpretation. For example, danger could refer to either long-term or short term health effects. Meanwhile, ease of use could refer to concealability, access, adverse reactions, or social acceptance. While outcomes could be interpreted differently, they likely reflect multifaceted perceptions with plausible roles in decision making. When considering risks and potential benefits of tobacco products, adolescents hold views that include multiple aspects of social and physical risks. For e-cigarettes, specifically, adolescents cite multiple influences, both related to the product itself and their social context. Adolescents’ smokeless tobacco use motivations likewise comprise multiple factors, including flavors, perceived nicotine strength, and loyalty to preferred brands.

The present study shows that several of these factors each independently contribute to multi-faceted perceptions. Among these dimensions, curiosity and ease-of use are strong predictors of tobacco use behaviors.Youth who perceived flavored smokeless tobacco and flavored e-cigarettes as easier to use than unflavored options were more likely to be susceptible to smokeless tobacco use and to initiate future e-cigarette use, respectively. The present discrete choice findings demonstrate that multiple independent product related factors are associated with constructs shown to predict future tobacco use.A study limitation is that discrete choice experiments ask participants to make hypothetical choices that may not resemble the actual setting in which purchase or use decisions are made. Provided only limited information, study participants may have based some selections on word associations outside the context of e-cigarettes or moist snuff, for example, connecting the words ‘tobacco’ or ‘cigalike’ with dangers expressed in anti-smoking messages or considering ‘fine cut’ to indicate high quality rather than the coarseness of moist snuff tobacco. However, adolescents, especially those inexperienced with tobacco use, are likely to possess limited product information in real-word settings and may make the same cognitive associations when evaluating a tobacco product from words on a package, advertisement, or warning. In this study, the presentation of images prior to initiating the textonly items may have helped mimic flavor imagery on packages or advertisements; however, it cannot be ruled out that the specific images or colors chosen had some influence on respondents’ choices. A strength of discrete choice survey methods is that the contributions of multiple characteristics are considered in combination, corresponding better to real-world product choices. However, this strength relies on the unverifiable assumption that participants make rational trade-offs between product characteristics when evaluating options. To our knowledge, this study represents the first to apply discrete choice techniques to a school-based sample of youth for both smokeless tobacco and e-cigarettes, including pod-type devices. A school-based design may yield a more representative sample in terms of social-economic profile and tobacco use experiences than an online panel. However, as a limitation,vertical farming supplies data collected in rural regions of California may not generalize nationally, including to other rural geographical locations. As a non-random sample, the generalizability of this study population is also limited. Advantageously, a rural sample is likely to have greater familiarity with moist snuff products. However, the small total number of moist snuff users did not yield ideal power to examine interactions by use status. Notably, public messaging from health authorities in California emphasizing the potential harms of e-cigarettes and nicotine could have resulted in more concern about nicotine in this sample than would be observed elsewhere.Cigarettes and alcohol are two of the most commonly used recreational substances. The 2018 National Health Interview Survey reported 19.7% using any tobacco product, including 13.7% using cigarettes and 3.2% using e-cigarettes . Of those using cigarettes, the prevalence of cigarette use was higher among men than women . The National Epidemiological Survey on Alcohol Related Conditions – III found that the 12-month prevalence of Diagnostic and Statistical Manual – 5 nicotine use disorder was 20.0%, while the prevalence of lifetime DSM-5 nicotine use disorder was 27.9% . In reference to cessation efforts, results from the NHIS revealed a significant increase in the prevalence of smoking quit attempts from 52.8% in 2009 to 55.1% in 2018, as well as a significant increase in successful quit attempts from 6.3% in 2009 to 7.5% in 2018 .

The impact of these high rates of cigarette use can be seen in the health consequences. The World Health Organization recently estimated that tobacco use contributed to more than 7 million deaths per year . Cigarette smoking has been linked with a variety of diseases including cardiovascular and respiratory diseases , gastrointestinal diseases , and numerous cancers with lung cancer being among the leading causes of cancer-related mortality that contribute to these high rates of morbidity and mortality. Cigarette smokers die approximately ten years earlier than non-smokers and cigarette smoking cessation prior to the age of 40 has been estimated to reduce risk of death by approximately 90% . In addition, to direct acute and chronic health consequences, smoking exerts a large economic burden with an estimated $130 billion due to direct medical healthcare and $130 billion due to lost work productivity resulting from premature death . Alcohol use rates to remain high with recent estimates from the 2019 National Survey on Drug Use and Health that 25.8% of adults in the U.S. reported engaging in binge drinking over the past month . Binge drinking was defined as 5 or more alcoholic beverages for men, and 4 or more alcoholic beverages for women on the same occasion at least one day in the past month. For DSM-5 alcohol use disorder , NESARC-III found a 12-month prevalence of 13.9% and lifetime prevalence of 29.1% . As with cigarettes, excessive alcohol consumption has been linked with a host of health consequences. Excessive alcohol use over an extended period of time has been associated with liver disease and cirrhosis , as well as increasing the risk for cancers including mouth, liver, and breast cancer . The economic burden caused by alcohol misuse was estimated in 2010 to reach $249 billion in the United States alone, with an estimated three-quarters of the cost due to binge drinking . The high rates of use across cigarettes and alcohol contribute to an array of health consequences that consequently result in a large economic burden. While alone these two substances are consumed at high rates, they are often used concurrently. In comparison to those who have never smoked, daily, occasional, and former smokers are all at greater risks of engaging in hazardous drinking . Daily and occasional smokers were also more likely to meet diagnostic criteria for a DSM-IV alcohol abuse or dependence diagnosis . A study of smokers who called into a smoking quit line found that 23% had reported hazardous drinking . Those who reported hazardous drinking also had significantly lower smoking cessation rates at a 1-week follow up than those who reported moderate alcohol consumption . This frequent pattern of co-use of alcohol and nicotine results in multiplicative health consequences for oral cancer and individuals who co-use are more likely face mortality from tobacco-related diseases than alcohol-related diseases . Previous reports have found smokers with an alcohol diagnosis are more likely to have more severe nicotine dependence . This can also be seen across the smoking trajectory, as smokers with past or current alcohol related problems are less likely to quit smoking across their lifetime . These high rates of use, coupled with the multiplicative adverse health consequences, suggest the presence of a bidirectional relationship between cigarettes and alcohol. Due to this robust bidirectional relationship, efforts have been made to understand the underlying neurobiological mechanisms perpetuating co-use between these substances. Prior studies have established this mesolimbic dopamine pathway as a pathway that plays a key role in mediating the subjective experience of reward, as well as reward seeking, for natural rewards and substances of abuse . This mesolimbic dopamine pathway originates with a cluster of neurons in midbrain region known as the ventral tegmental area that project dopaminergic neurons into an area of the forebrain known as the nucleus accumbens . Dopamine is released in the NAcc when stimulated by natural or artificial rewards. The mesolimbic dopamine pathway serves a central role in the rewarding effects of substances of abuse. Multiple mechanisms have been proposed to explain the co-use of nicotine and alcohol.