Modification de la composition des cigarettes durant te XXe siècle: rôle de l'industrie du tabac et effet sur la dépendance tabagique [Chemicals added to cigarettes and their effects on tobacco dependence]

This paper summarizes data on the factors involved in addiction and dependence to cigarettes. Nicotine has been intensively studied by the tobacco industry, for instance for its addictive effect at the lowest possible rates. The addition of diammonium phosphate and urea produces an alcalinization of the pH of cigarette smoke, and promotes the absorption and the trans-membrane passage of nicotine. The taste, the smell of smoke, and the visual aspect of the pack of cigarettes are also sensory components that promote addiction. Finally, menthol, sugar, cocoa and liquorice added to cigarettes also play a role in dependence and addiction to cigarettes by, for instance, making an anesthetic effect on the airways.

Is cannabis use a significant exposition to nicotine?

Purpose: Young cannabis users are at increased risk for cigarette initiation and later progression to nicotine dependence. The present study assesses to which extent cannabis users are exposed to nicotine through mulling, a widespread process consisting of mixing tobacco to cannabis for its consumption. Methods: Data are issued from an ongoing observational study taking place in Switzerland. A total of 267 eligible participants (mean age 19 years, 46.4% males) completed an anonymous self-administered questionnaire on their tobacco and cannabis intake in the previous 5 days. They also provided a urine sample that was blindly analyzed for cotinine (a key metabolite of nicotine) using liquid-chromatography coupled mass-spectrometry. After the exclusion of cannabis users not having smoked at least one joint/blunt in which tobacco had been mixed (n _ 2), and participants reporting other sources of nicotine exposition than cigarettes or mulling (n _37), four groups were created: cannabis and cigarette abstainers (ABS, n_ 69), cannabis only smokers (CAS; n _ 33), cigarette only smokers (CIS; n _ 62); and cannabis and cigarette smokers (CCS, n _ 64). Cotinine measures of CAS were compared to those of ABS, CIS and CCS. All comparisons were performed using ANCOVA, controlling for age, gender, ethnicity, BMI and environmental exposure to cigarette smoke in the past month (at home, in school/at work, in social settings). The number of mixed joints/blunts smoked in the previous 5 days was additionally taken into account when comparing CAS to CCS. Cotinine values (ng/ml) are reported as means with 95% confidence interval (95% CI). Results: In the previous 5 days, CAS had smoked on average 10 mixed joints/blunts, CIS 30 cigarettes, and CCS 8 mixed joints/ blunts and 41 cigarettes. Cotinine levels of participants considerably differed between groups. The lowest measure was found among ABS (3.2 [0.5-5.9]), followed in growing order by CAS (294.6 [157.1-432.0]), CIS (362.8 [258.4-467.3]), and CCS (649.9 [500.7-799.2]). In the multivariate analysis, cotinine levels of CAS were significantly higher than those of ABS (p _.001), lower than those of CCS (p _ .003), but did not differ from levels of CIS (p _ .384). Conclusions: Our study reveals cannabis users to be significantly exposed to nicotine through mulling, even after controlling for several possible confounders such as environmental exposure to cigarette smoke. Utmost, mixing tobacco to Poster cannabis can result in a substantial nicotine exposition as cotinine levels from cannabis only smokers were as high as those of moderate cigarette smokers. Our findings also suggest that mulling is adding up to the already important nicotine exposition of cigarettes smokers. Because of the addictiveness of nicotine, mulling should be part of a comprehensive assessment of substance use among adolescents and young adults, especially when supporting their cannabis and cigarette quitting attempts. Sources of Support: This study was funded by the Public Health Service of the Canton de Vaud. Dr. BÊlanger's contribution was possible through grants from the Royal College of Physicians and Surgeons of Canada, the CHUQ/CMDP Foundation and the Laval University McLaughlin program, QuÊbec, Canada.

Risk perception and emotional coping: a pathway for behavioural addiction?

This article summarizes current concepts of the working memory with regard to its role within emotional coping strategies. In particular, it focuses on the fact that the limited capacity of the working memory to process now-relevant information can be turned into an advantage, when the individual is occupied by dealing with unpleasant emotion. Based on a phenomenon known as dual-task interference (DTI), this emotion can be chased by intense arousal due to clearly identifiable external stressors. Thus, risk perception might be used as a 'DTI inductor' that allows avoidance of unpleasant emotion. Successful mastery of risk adds a highly relevant dopaminergic component to the overall experience. The resulting mechanism of implicit learning may contribute to the development of a behavioural addiction. Besides its putative effects in the development of a behavioural addiction, the use of DTI might be of a more general interest for the clinical practice, especially in the field of psychotherapy. © 2013 S. Karger AG, Basel.

Interventions for smoking cessation in hospitalised patients.

BACKGROUND: Smoking contributes to reasons for hospitalisation, and the period of hospitalisation may be a good time to provide help with quitting. OBJECTIVES: To determine the effectiveness of interventions for smoking cessation that are initiated for hospitalised patients. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group register which includes papers identified from CENTRAL, MEDLINE, EMBASE and PsycINFO in December 2011 for studies of interventions for smoking cessation in hospitalised patients, using terms including (hospital and patient*) or hospitali* or inpatient* or admission* or admitted. SELECTION CRITERIA: Randomized and quasi-randomized trials of behavioural, pharmacological or multicomponent interventions to help patients stop smoking, conducted with hospitalised patients who were current smokers or recent quitters (defined as having quit more than one month before hospital admission). The intervention had to start in the hospital but could continue after hospital discharge. We excluded studies of patients admitted to facilities that primarily treat psychiatric disorders or substance abuse, studies that did not report abstinence rates and studies with follow-up of less than six months. Both acute care hospitals and rehabilitation hospitals were included in this update, with separate analyses done for each type of hospital. DATA COLLECTION AND ANALYSIS: Two authors extracted data independently for each paper, with disagreements resolved by consensus. MAIN RESULTS: Fifty trials met the inclusion criteria. Intensive counselling interventions that began during the hospital stay and continued with supportive contacts for at least one month after discharge increased smoking cessation rates after discharge (risk ratio (RR) 1.37, 95% confidence interval (CI) 1.27 to 1.48; 25 trials). A specific benefit for post-discharge contact compared with usual care was found in a subset of trials in which all participants received a counselling intervention in the hospital and were randomly assigned to post-discharge contact or usual care. No statistically significant benefit was found for less intensive counselling interventions. Adding nicotine replacement therapy (NRT) to an intensive counselling intervention increased smoking cessation rates compared with intensive counselling alone (RR 1.54, 95% CI 1.34 to 1.79, six trials). Adding varenicline to intensive counselling had a non-significant effect in two trials (RR 1.28, 95% CI 0.95 to 1.74). Adding bupropion did not produce a statistically significant increase in cessation over intensive counselling alone (RR 1.04, 95% CI 0.75 to 1.45, three trials). A similar pattern of results was observed in a subgroup of smokers admitted to hospital because of cardiovascular disease (CVD). In this subgroup, intensive intervention with follow-up support increased the rate of smoking cessation (RR 1.42, 95% CI 1.29 to 1.56), but less intensive interventions did not. One trial of intensive intervention including counselling and pharmacotherapy for smokers admitted with CVD assessed clinical and health care utilization endpoints, and found significant reductions in all-cause mortality and hospital readmission rates over a two-year follow-up period. These trials were all conducted in acute care hospitals. A comparable increase in smoking cessation rates was observed in a separate pooled analysis of intensive counselling interventions in rehabilitation hospitals (RR 1.71, 95% CI 1.37 to 2.14, three trials). AUTHORS' CONCLUSIONS: High intensity behavioural interventions that begin during a hospital stay and include at least one month of supportive contact after discharge promote smoking cessation among hospitalised patients. The effect of these interventions was independent of the patient's admitting diagnosis and was found in rehabilitation settings as well as acute care hospitals. There was no evidence of effect for interventions of lower intensity or shorter duration. This update found that adding NRT to intensive counselling significantly increases cessation rates over counselling alone. There is insufficient direct evidence to conclude that adding bupropion or varenicline to intensive counselling increases cessation rates over what is achieved by counselling alone.

Predictors of onset of cannabis and other drug use in male young adults: results from a longitudinal study.

BACKGROUND: The use of cannabis and other illegal drugs is particularly prevalent in male young adults and is associated with severe health problems. This longitudinal study explored variables associated with the onset of cannabis use and the onset of illegal drug use other than cannabis separately in male young adults, including demographics, religion and religiosity, health, social context, substance use, and personality. Furthermore, we explored how far the gateway hypothesis and the common liability to addiction model are in line with the resulting prediction models. METHODS: The data were gathered within the Cohort Study on Substance Use Risk Factors (C-SURF). Young men aged around 20 years provided demographic, social, health, substance use, and personality-related data at baseline. Onset of cannabis and other drug use were assessed at 15-months follow-up. Samples of 2,774 and 4,254 individuals who indicated at baseline that they have not used cannabis and other drugs, respectively, in their life and who provided follow-up data were used for the prediction models. Hierarchical logistic stepwise regressions were conducted, in order to identify predictors of the late onset of cannabis and other drug use separately. RESULTS: Not providing for oneself, having siblings, depressiveness, parental divorce, lower parental knowledge of peers and the whereabouts, peer pressure, very low nicotine dependence, and sensation seeking were positively associated with the onset of cannabis use. Practising religion was negatively associated with the onset of cannabis use. Onset of drug use other than cannabis showed a positive association with depressiveness, antisocial personality disorder, lower parental knowledge of peers and the whereabouts, psychiatric problems of peers, problematic cannabis use, and sensation seeking. CONCLUSIONS: Consideration of the predictor variables identified within this study may help to identify young male adults for whom preventive measures for cannabis or other drug use are most appropriate. The results provide evidence for both the gateway hypothesis and the common liability to addiction model and point to further variables like depressiveness or practising of religion that might influence the onset of drug use.

Use of nicotine substitute prescribed at hourly plus ad libitum intake or ad libitum for heavy smokers willing to quit : a randomized controlled trial

Rapport de synthèse : l .Objectif Evaluer l'effet qu'ont les consignes d'utilisation régulière d'un spray nasal à la nicotine sur leur véritable utilisation durant les 3 premières semaines d'un sevrage tabagique. Un objectif secondaire est d'évaluer l'effet des consignes d'utilisation régulière du spray durant les premières semaines de sevrage tabagique sur le taux de succès à 6 mois par rapport à un groupe pouvant utiliser le spray « ad libitum ». 2. Méthode II s'agit d'une étude ouverte, randomisée contrôlée, incluant 50 patients présentant une dépendance nicotinique forte, se trouvant en phase de préparation selon le modèle transthéorique du changement de Prochaska et Di Clemente, recrutés au sein de la consultation «stop tabac » de la Policlinique Médicale Universitaire de Lausanne. Dans le groupe «contrôle », les patients ont été instruits à utiliser le spray « ad libitum », soit dès qu'apparaissaient des envies irrésistibles de fumer, tandis que le groupe «intervention » a reçu pour consigne d'utiliser le spray au moins 1 fois par heure dès le lever, voire plus en cas d'envie de fumer. L'utilisation du spray nasal a été enregistrée par un dispositif électronique fixé sur le spray (MDILogTM) durant les 3 premières semaines d'utilisation. Durant le suivi, l'abstinence tabagique a été vérifiée par une mesure du taux de CO expiré par un appareil spécifique (Bedfont Smokerlyzer). L'abstinence tabagique a été considérée comme un succès si le taux de CO était s 10 ppm (particules par million). 3. Résultats Un patient a été perdu durant le suivi. Au moment de la randomisation, le groupe «intervention » comprenait plus de femmes, des patients ayant un nombre plus grand de précédentes tentatives d'arrêt du tabagisme, plus de co-morbidités psychiatriques, mais moins de co-morbidités somatiques que le groupe «contrôle ». Dans les 2 groupes, les participants ont utilisé le spray nasal plus de 8 fois par jour (minimum demandé dans le groupe intervention). L'utilisation moyenne du spray était de 13,6 doses/jour pour le groupe «intervention » et de 1 l,l doses/jour pour le groupe contrôle. Ajusté aux différences entre les 2 groupes, la différence entre les doses plus importantes utilisées dans le groupe «intervention »par rapport à celles du groupe « ad libitum »reste non significative durant la première (0.8 ; CI 95% -5.1 ; 6,7), la deuxième (4.0 ; CI 95% -1.9 ; 9.9) et la troisième semaine (3.0 ; CI 95% -2.5 ; 8.5). De même, le fait d'instruire le patient à utiliser chaque heure le spray nasal durant les premières semaines n'a pas eu d'impact sur le taux de succès à 6 mois (RR = 0.69 ; CI 95% 0.34 ; 1.39). 4. Conclusions Cette étude négative montre que les différences d'utilisation du spray nasal nicotinique sont plus dépendantes des caractéristiques individuelles du patient que des recommandations d'utilisation du thérapeute. Les patients présentant un syndrome de dépendance à la nicotine forte utilisent spontanément de manière importante le spray nasal nicotinique, indépendamment des recommandations données. Pour les patients présentant un syndrome de dépendance à la nicotine forte, les recommandations par le thérapeute d'utiliser le spray nasal dès l'apparition d'envies de fumer semblent être la manière de faire la plus adéquate.

Second hand tobacco smoke exposure in Switzerland

A passive sampling device called Monitor of NICotine or "MoNIC", was constructed and evaluated by IST laboratory for determining nicotine in Second Hand Tobacco Smoke (SHTS) or Environmental Tobacco Smoke (ETS). Vapour nicotine was passively collected on a potassium bisulfate treated glass fibre filter as collection medium. Analysis of collected nicotine on the treated filter by gas chromatography equipped with Thermoionic-Specific Detector (GC-TSD) after liquid-liquid extraction of 1mL of 5N NaOH : 1 mL of n-heptane saturated with NH3 using quinoline as internal standard. Based on nicotine amount of 0.2 mg/cigarette as the reference, the inhaled Cigarette Equivalents (CE) by non-smokers can be calculated. Using the detected CE on the badge for non-smokers, and comparing with amount of nicotine and cotinine level in saliva of both smokers and exposed non-smokers, we can confirm the use of the CE concept for estimating exposure to ETS. The regional CIPRET (Center of information and prevention of the addiction to smoking) of different cantons (Valais (VS), Vaud (VD), Neuchâtel (NE) and Fribourg (FR)) are going to organize a big campaign on the subject of the passive addiction to smoking. This campaign took place in 2007-2008 and has for objective to inform clearly the Swiss population of the dangerousness of the passive smoke. More than 3'900 MoNIC badges were gracefully distributed to Swiss population to perform a self-monitoring of population exposure level to ETS, expressed in term of CE. Non-stimulated saliva was also collected to determine ETS biomarkers nicotine/cotinine levels of participating volunteers. Results of different levels of CE in occupational and non-occupational situations in relation with ETS were presented in this study. This study, unique in Switzerland, has established a base map on the population's exposure to SHTS. It underscored the fact that all the Swiss people involved in this campaign (N=1241) is exposed to passive smoke, from <0.2 cig/d (10.8%), 1-2 to more than 10 cig/d (89.2%). In the area of high exposure (15-38 cig/d), are the most workers in public restaurant, cafe, bar, disco. By monitoring ETS tracer nicotine and its biomarkers, salivary nicotine and cotinine, it is demonstrated that the MoNIC badge can serve as indicator of CE passive smoking. The MoNIC badge, accompanied with content of salivary nicotine/cotinine can serve as a tool of evaluation of the ETS passive smoking and contributes to supply useful data for future epidemiological studies. It is also demonstrated that the salivary nicotine (without stimulation) is a better biomarker of ETS exposure than cotinine.

To what extent does adding tobacco to cannabis expose young users to nicotine?

INTRODUCTION: To determine if mulling, the process of adding tobacco to cannabis for its consumption, exposes young cannabis users to significant levels of nicotine. METHODS: This observational study performed in 2009-2010 among Swiss youths aged 16-25 years involved the completion of a self-administrated questionnaire and the collection of a urine sample on the same day. Measures of urinary cotinine were blindly performed using liquid chromatography coupled-mass spectrometry. A total of 197 eligible participants were divided in 3 groups based on their consumption profile in the past 5 days: 70 abstainers (ABS) not having used cigarettes or cannabis, 57 cannabis users adding tobacco to the cannabis they smoke (MUL) but not having smoked cigarettes, and 70 cigarette smokers (CIG) not having smoked cannabis. RESULTS: Exposure to nicotine was at its lowest among ABS with a mean (SE) cotinine level of 3.2 (1.4) ng/ml compared, respectively, with 214.6 (43.8) and 397.9 (57.4) for MUL and CIG (p < .001). While consumption profile appeared as the only significant factor of influence when examining nicotine exposure from the ABS and MUL participants on multivariate analysis, it did not result in substantial differences among MUL and CIG groups. CONCLUSIONS: Urinary cotinine levels found among MUL are high enough to indicate a significant exposure to nicotine originating from the mulling process. In line with our results, health professionals should pay attention to mulling as it is likely to influence cannabis and cigarette use as well as the efficacy of cessation interventions.

Nouveaux modes de consommation du tabac et de la nicotine [New modes of tobacco and nicotine use]

New ways of consuming tobacco or nicotine have recently been developed attracting smokers not only because of their novelty but also because they hope that it will decrease their health risks or will help them in smoking banned places. The objective of this paper is to review the current state of knowledge concerning the waterpipe, oral tobacco, nasal snuff, the electronic cigarette and tobacco heating devices. Although some products seem less harmful than cigarettes, we cannot encourage people to use them because we still do not have sufficient scientific data regarding their safety. Moreover, most of these products are addictive and we still do not know if they will play a role in harm reduction.

Dépendances [Addiction].

The news in addiction medicine for 2010 include somatic, neuroscientific as well as psychotherapeutic aspects. First are considered the risks of cardiac arythmy with methadone as long as the racemate form is prescribed in Switzerland. Then the neurosciences bring their usual novelties in the field of the addictions, this year in relational neuroscience and in the relationship between trauma and addiction. At last a contribution bridges the notion of low threshold treatment with the psychodynamic approach.

Evidence for an overestimated vulnerability of adolescent rats to develop signs of drug addiction

Drug addiction is a multi-etiological disorder to which some individuals are more vulnerable an others. Whereas converging clinical and epidemiological studies report a peak of drug use ring adolescence, many behavioral traits characterizing teenagers have been proposed to contribute to this vulnerability, including a heightened sensation-seeking, an enhanced impulsivity d a larger influence exerted by peers. By many aspects, juvenile rodents display behavioral traits at resemble those of teenagers. However, the concept of increased vulnerability to drug addiction juvenile rats remains in debate. Indeed, only a few studies directly compared juvenile and adult fdents regarding behavioral predictors of drug abuse. Moreover, some key features of drug diction have never been investigated in juvenile rats yet. For this very reason, we conducted a arge-scale behavioral comparison of adult and adolescent rats with the aim of dissecting their espective behavioral traits and vulnerabilities to drug addiction. We first have shown that juvenile rats exhibited an enhanced motor impulsivity, and a loss of control over reward seeking assessed by a persistent reward taking despite adverse consequences mild electric footshocks]. We also report that juvenile rats displayed a higher anxiety profile, ind we discuss why these behaviors might represent key underpinning mechanisms leading to an enhanced vulnerability to drug abuse. Meanwhile, we collected clear cut observations that do not support such an interpretation. In Articular, juvenile and adult rats displayed identical novelty-induced habituation and preference at are considered to represent two potent predictors of cocaine initiation and compulsive intake, "pre strikingly, juvenile rats were less attracted by cues predicting reward in a Pavlovian utoshaping task, suggesting a lower propensity for cues or context to trigger the reinstatement of a^previously extinguished reward seeking behavior. Finally, using a paradigm assessing schedule- ciuced polydipsia, juvenile and adult rats exhibited similar compulsive drinking, under control conditions and following a chronic cocaine treatment as well. Hence, these observations call for a cautious interpretation of adolescent vulnerability to drug use. In particular, we underlined that even the most compulsive young rats did not consume ärger amounts of cocaine than adults, nor exhibited larger efforts in a cue-induced relapse aradigm, despite a transient increased motivation for lever-pressing. And further, despite a higher ensitivity to the behavioral effects of cocaine, juvenile rats did not differ from adults in their ropensity to constantly prefer saccharin over cocaine in a discrete-choice procedure, even after a ?'Id chronic stress procedure. Altogether, our results shape an objective overview of the juvenile rats' behavior in relation to oth drug and non-drug rewards, suggesting a heterogeneous and task-specific profile. Despite elements potentially underlying a real risk for substance use, adolescent rats do not exhibit a ehavioral repertoire suggesting increased vulnerability for compulsive drug abuse. Our conclusions strongly encourage deeper neurobiological investigations of the developing brain, and also open a debate on a possible overestimation of juvenile rats' and teenager's risk to develop aladaptive behaviors and drug addiction. - L'addiction aux drogues est une pathologie d'origine multifactorielle, à laquelle certains individus sont plus vulnérables que d'autres. De nombreuses études cliniques et épidémiologiques suggèrent une consommation excessive de drogues pendant l'adolescence, et plusieurs explications ont été avancées pour justifier cette tendance, parmi lesquelles on note une augmentation de la recherche de sensation, une impulsivité plus marquée et une plus forte influence de l'entourage. Le rat juvénile présente de nombreuses caractéristiques développementales similaires à l'adolescence humaine. En revanche, la vulnérabilité des rats juvéniles à l'abus de drogue est encore sujette à caution. En effet, peu d'études ont directement comparé des traits de comportements pouvant refléter un accroissement du risque d'abus chez les rats juvéniles par comparaison aux rats adultes. En outre, certaines caractéristiques fondamentales de l'addiction chez l'homme n'ont pas encore été étudiées chez le rat adolescent. Ce travail de thèse s'est donc donné pour objectif de comparer le comportement de rats adultes vis-à-vis de celui de rats adolescents, afin d'évaluer dans quelle mesure ces derniers seraient plus vulnérables à l'abus de drogues. Nos résultats indiquent que les rats juvéniles présentent une augmentation des comportements impulsifs, ainsi qu'une plus grande persistance à rechercher de manière compulsive une récompense en dépit de légers chocs électriques. Les rats juvéniles présentent également un profil anxieux plus élevé, ce qui peut constituer une autre source de vulnérabilité. Cependant, certaines caractéristiques comportementales ne suggèrent pas de vulnérabilité chez les rats juvéniles. Aucune différence entre rats adultes et adolescents n'a été trouvée pour l'habituation et la préférence pour la nouveauté, deux traits prédisant l'initiation et la prise compulsive de drogue. De plus, nous avons montré que les rats adolescents attribuent moins d'intérêt à des stimuli prédisant la disponibilité d'une récompense, suggérant une vulnérabilité plus faible à la rechute induite par les stimuli associés à la prise de drogue. Une étude complémentaire des comportements compulsifs indique une absence de différence entre rats adultes et adolescents, à la fois en condition basale ou après un traitement chronique à la cocaïne. L'étude des comportements de prise de drogue ne va pas non plus dans le sens d'une vulnérabilité des rats adolescents. Bien que les rats compulsifs sélectionnés pendant la période juvénile présentent une plus grande motivation à prendre de la cocaïne, ils ne diffèrent ni dans la quantité de cocaïne consommée, ni dans la rechute induite par les stimuli environnementaux. En dépit d'une sensibilisation comportementale plus importante, les rats adolescents présentent la même préférence que les adultes face à un choix entre une drogue et une récompense alternative, suggérant une résilience à la cocaïne comparable à celle des adultes. Enfin, cette résilience pour la cocaïne n'est pas affectée par un stress chronique lors de l'adolescence. En résumé, cette étude dresse un regard objectif sur les comportements en lien avec une vulnérabilité à l'abus de drogues chez le rat juvénile, suggérant que celle-ci est hétérogène et spécifique au protocole utilisé. En dépit de certains éléments de vulnérabilité, les rats adolescents ne présentent pas d'attirance excessive pour la cocaïne, ni de prédisposition à la consommation compulsive de cette drogue. L'ensemble de ces éléments pourra constituer une base solide pour l'investigation neurobiologique du cerveau en développement, et ouvre un débat sur une possible surestimation de la vulnérabilité des rats juvéniles et de leurs homologues humains aux pathologies psychiatriques telles que l'addiction aux drogues.

2013 Update in addiction medicine for the generalist.

Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles' merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.