Immediate antecedents of cigarette smoking: an analysis from ecological momentary assessment

Anxiety sensitivity and marijuana use: an analysis from ecological momentary assessment

BACKGROUND

The cognitive factor of Anxiety Sensitivity (AS; the fear of anxiety and related bodily sensations) is theorized to play a role in cannabis use and its disorders. Lower-order facets of AS (physical concerns, mental incapacitation concerns, and social concerns) may be differentially related to cannabis use behavior. However, little is known about the impact of AS facets on the immediate antecedents of cannabis use.

METHODS

This study used ecological momentary assessment (EMA) to prospectively examine the relations between specific facets of AS, cannabis craving, state anxiety, and cannabis use in the natural environment using real-world data about ad lib cannabis use episodes. Participants were 49 current cannabis users (38.8% female).

RESULTS

AS-mental incapacitation fears were related to significantly greater severity of cannabis-related problems at baseline. During the EMA period, AS-mental incapacitation and AS-social concerns significantly interacted with cannabis craving to prospectively predict subsequent cannabis use. Specifically, individuals with higher craving and either higher AS-mental incapacitation or AS-social concerns were the most likely to subsequently use cannabis. In contrast to prediction, no AS facet significantly moderated the relationship between state anxiety and cannabis use.

CONCLUSIONS

These findings suggest facets of AS (mental incapacitation and social fears) interact with cannabis craving to predict cannabis use. Findings also suggest differential relations between facets of AS and cannabis-related behaviors.

Stress decreases the ability to resist smoking and potentiates smoking intensity and reward

We have developed a novel human laboratory model to examine two primary aspects of stress-precipitated tobacco relapse: (1) Does stress reduce the ability to resist the first cigarette? (2) Once the first cigarette is initiated, does stress facilitate subsequent smoking? Using a within-subject design, daily smokers (n = 37) who were nicotine deprived overnight received a personalized imagery induction (stress or neutral) on two separate days, and then had the option of initiating a tobacco self-administration session or delaying initiation for up to 50 min in exchange for three levels of monetary reinforcement. Subsequently, the tobacco self-administration session entailed a 1-hour period in which subjects could choose to smoke using a smoking topography system. Following the stress induction, subjects were less able to resist smoking, smoked more intensely (increased puffs, shorter inter-puff interval, and greater peak puff velocity), and perceived greater satisfaction and reward from smoking. Stress significantly increased hypothalamus-pituitary-adrenal (HPA) axis reactivity, tobacco craving, negative emotion, and physiologic reactivity relative to the neutral condition. In addition, increased cortisol, ACTH, and tobacco craving were associated with reduced ability to resist smoking following stress. These findings have implications for understanding the impact of stress on smoking relapse and model development to assess smoking lapse behavior.

New methods for tobacco dependence treatment research

INTRODUCTION

Despite advances in tobacco dependence treatment in the past two decades, progress has been inconsistent and slow. This paper reviews pervasive methodological issues that may contribute to the lack of timely progress in tobacco treatment science including the lack of a dynamic model or framework of the cessation process, inefficient study designs, and the use of distal outcome measures that poorly index treatment effects. The authors then present a phase-based cessation framework that partitions the cessation process into four discrete phases based on current theories of cessation and empirical data. These phases include: (1) Motivation, (2) Precessation, (3) Cessation, and (4) Maintenance.

DISCUSSION

Within this framework, it is possible to identify phase-specific challenges that a smoker would encounter while quitting smoking, intervention components that would address these phase-specific challenges, mechanisms via which such interventions would exert their effects, and optimal outcome measures linked to these phase-specific interventions. Investigation of phase-based interventions can be accelerated by using efficient study designs that would permit more timely development of an optimal smoking cessation treatment package.

An Ecological Momentary Assessment analysis of relations among coping, affect and smoking during a quit attempt

AIMS

This study used Ecological Momentary Assessment (EMA) data from smokers trying to quit to assess relations among coping, positive affect, negative affect and smoking. The effects of stress coping on affect and smoking were examined.

DESIGN

Data from a randomized clinical trial of smoking cessation treatments were submitted to multi-level modeling to test the effects of coping with stressful events on subsequent affect and smoking.

SETTING

Center for Tobacco Research and Intervention, Madison, Wisconsin.

PARTICIPANTS

A total of 372 adult daily smokers who reported at least one stressful event and coping episode and provided post-quit data.

MEASUREMENTS

Participants' smoking, coping and affect were assessed in near real time with multiple EMA reports using electronic diaries pre- and post-quit.

FINDINGS

Multi-level models indicated that a single coping episode did not predict a change in smoking risk over the next 4 or 48 hours, but coping in men was associated with concurrent reports of increased smoking. Coping predicted improved positive and negative affect reported within 4 hours of coping, but these affective gains did not predict reduced likelihood of later smoking. Pre-quit coping frequency and gender moderated post-quit stress coping relations with later positive affect. Men and those with greater pre-quit coping frequency reported greater gains in positive affect following post-quit coping.

CONCLUSIONS

Coping responses early in a quit attempt may help smokers trying to quit feel better, but may not help them stay smoke-free.

Does extinction of responses to cigarette cues occur during smoking cessation?

AIMS

This study investigated whether Pavlovian extinction occurs during smoking cessation by determining whether experience abstaining from smoking in the presence of cigarette cues leads to decreased probability of lapsing and whether this effect is mediated by craving.

DESIGN

Secondary analyses were carried out with data sets from two studies with correlational/observational designs.

SETTING

Data were collected in smokers' natural environments using ecological momentary assessment techniques.

PARTICIPANTS

Sixty-one and 207 smokers who were attempting cessation participated.

MEASUREMENTS

Multi-level path models were used to examine effects of prior experience abstaining in the presence of available cigarettes and while others were smoking on subsequent craving intensity and the probability of lapsing. Control variables included current cigarette availability, current exposure to others smoking, number of prior lapses and time in the study.

FINDINGS

Both currently available cigarettes [odds ratios (OR) = 36.60, 11.59] and the current presence of other smoking (OR = 5.00, 1.52) were powerful predictors of smoking lapse. Repeated exposure to available cigarettes without smoking was associated with a significantly lower probability of lapse in subsequent episodes (OR = 0.44, 0.52). However, exposure to others smoking was not a reliable predictor, being significant only in the smaller study (OR = 0.30). Craving functioned as a mediator between extinction of available cigarettes and lapsing only in the smaller study and was not a mediator for extinction of others smoking in either study.

CONCLUSIONS

This study showed that exposure to available cigarettes is a large risk factor for lapsing, but that this risk can also be reduced over time by repeated exposures without smoking. Smoking cessation interventions should attempt to reduce cigarette exposure (by training cigarette avoidance) but recognize the potential advantage of unreinforced exposure to available cigarettes.

A multimodal approach to assessing the impact of nicotine dependence, nicotine abstinence, and craving on negative affect in smokers

We used multimodal measurement to evaluate whether (a) nicotine dependence is associated with baseline and postquit negative affect and craving, (b) smoking relapse is associated with greater negative affect and craving than abstinence, and (c) craving is associated with negative affect. Treatment-seeking smokers were randomly assigned to either a brief behaviorally based smoking-cessation treatment condition or to a delayed treatment control condition. Participants in the treatment condition attended four assessment sessions, 4-5 days prequit (baseline), 1-2 days postquit, 3-5 days postquit, and 10-14 days postquit, while controls attended four sessions spaced over the same intervals. Retrospective questionnaires were collected at the beginning of each session, and corrugator EMG and in-session ratings were collected during viewing of affective and cigarette-related slides. The multimodal measures indicated that more dependent smokers experienced greater negative affect and craving at baseline and postquit, regardless of abstinence status. The self-report measures indicated that both relapsed and abstinent smokers reported greater negative affect and craving than control smokers. Craving was associated with negative affect across measurement modalities. These results highlight the benefits of using multimodal measures to study the impact of nicotine dependence and withdrawal on negative affect and craving.

Nicotine competes with a visual stimulus for control of conditioned responding

Environmental stimuli that co-occur with tobacco use come to evoke drug-related conditioned responses (CRs) that appear involved in continued use of nicotine-containing products. In rats, nicotine can serve as a conditional stimulus (CS) for non-drug unconditioned stimuli (USs), prompting the question of whether the nicotine CS can compete with, or overshadow, a non-drug environmental stimulus for control of a CR. In Experiment 1, male Sprague-Dawley rats were assigned to a group [0, 0.01, 0.03, 0.045, or 0.06 mg nicotine (base)/kg/infusion]. During each session, there were 10 intravenous infusions followed by a 30-second houselight to form a compound CS. At light offset there was 4-second access to sucrose. For Experiment 2, groups were nicotine (0.03 mg/kg/infusion) + light compound paired, nicotine + light compound unpaired, nicotine paired and light unpaired, and nicotine unpaired and light paired. Paired stimuli were presented with sucrose similar to Experiment 1. Unpaired stimuli were temporally separated from sucrose. Following acquisition, tests of nicotine and light alone were conducted by intermixing non-reinforced trails into training sessions. Nicotine dose-dependently overshadowed the light CS as shown by reduced light control of conditioned responding with higher doses. The nicotine, light, and nicotine + light compound had to be paired with sucrose to evoke a CR. These results demonstrate nicotine overshadows an exteroceptive visual stimulus. Because exteroceptive stimuli are often the focus of cue-exposure therapy, such competition may help begin to explain the marginal effectiveness of these therapies.

Conceptualizing and Estimating Process Speed in Studies Employing Ecological Momentary Assessment Designs: A Multilevel Variance Decomposition Approach

Researchers have been making use of ecological momentary assessment (EMA) and other study designs that sample feelings and behaviors in real time and in naturalistic settings to study temporal dynamics and contextual factors of a wide variety of psychological, physiological, and behavioral processes. As EMA designs become more widespread, questions are arising about the frequency of data sampling, with direct implications for participants' burden and researchers' ability to capture and study dynamic processes. Traditionally, spectral analytic techniques are used for time series data to identify process speed. However, the nature of EMA data, often collected with fewer than 100 measurements per person, sampled at randomly spaced intervals, and replete with planned and unplanned missingness, precludes application of traditional spectral analytic techniques. Building on principles of variance partitioning used in the generalizability theory of measurement and spectral analysis, we illustrate the utility of multilevel variance decompositions for isolating process speed in EMA-type data. Simulation and empirical data from a smoking-cessation study are used to demonstrate the method and to evaluate the process speed of smoking urges and quitting self-efficacy. Results of the multilevel variance decomposition approach can inform process-oriented theory and future EMA study designs.

The Role of the Self in Smoking Initiation and Smoking Cessation: A Review and Blueprint for Research at the Intersection of Social-Cognition and Health

The self-concept is recognized as important to both smoking initiation and cessation. However, most of extant research has viewed the self-concept as a static, monolithic construct. It has not drawn on contemporary social-cognitive theories of the self-concept, which view the self-concept as a dynamic, multi-faceted cognitive structure that regulates behavior in context. This paper discusses a contemporary social cognitive framework that can be used to understand the role of the self-concept in smoking.

Light smoking in a predominantly Hispanic college student sample: a 7 day diary assessment

Both Hispanic and college student populations smoke at non trivial rates but less frequently than other smoking groups. Limited information exists about the at risk times for smoking among those who smoke fewer than 10 cigarettes per day, particularly college students. Participants (n=116 young adults) completed a 7 day Tobacco Consumption Diary by recording for each cigarette smoked: time and day, location, number of people present, number of smokers present, mood, and whether alcohol was consumed. Descriptive analyses suggest a variety of psycho-social contexts within which light smoking may occur for a predominantly Hispanic sample of college students. Inferential analyses reveal a somewhat heterogeneous pattern of light smoking. Nevertheless, Thursday, Friday, and Saturday, as well as later hours of each day in particular are associated with an increased likelihood of smoking. Further study of intra-individual patterns of both Hispanic and college student light smoking is needed to identify the ideographic triggers that can be intervened upon to aid light smokers in cessation.

Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention

OBJECTIVE

A strong relation between negative affect and craving has been demonstrated in laboratory and clinical studies, with depressive symptomatology showing particularly strong links to craving and substance abuse relapse. Mindfulness-based relapse prevention (MBRP), shown to be efficacious for reduction of substance use, uses mindfulness-based practices to teach alternative responses to emotional discomfort and lessen the conditioned response of craving in the presence of depressive symptoms. The goal in the current study was to examine the relation between measures of depressive symptoms, craving, and substance use following MBRP.

METHOD

Individuals with substance use disorders (N = 168; mean age 40.45 years, SD = 10.28; 36.3% female; 46.4% non-White) were recruited after intensive stabilization, then randomly assigned to either 8 weekly sessions of MBRP or a treatment-as-usual control group. Approximately 73% of the sample was retained at the final 4-month follow-up assessment.

RESULTS

Results confirmed a moderated-mediation effect, whereby craving mediated the relation between depressive symptoms (Beck Depression Inventory) and substance use (Timeline Follow-Back) among the treatment-as-usual group but not among MBRP participants. MBRP attenuated the relation between postintervention depressive symptoms and craving (Penn Alcohol Craving Scale) 2 months following the intervention (f(2) = .21). This moderation effect predicted substance use 4 months following the intervention (f(2) = .18).

CONCLUSION

MBRP appears to influence cognitive and behavioral responses to depressive symptoms, partially explaining reductions in postintervention substance use among the MBRP group. Although results are preliminary, the current study provides evidence for the value of incorporating mindfulness practice into substance abuse treatment and identifies a potential mechanism of change following MBRP.

In-clinic use of electronic pain diaries: barriers of implementation among pain physicians

OBJECTIVES

The aim of this study was to examine barriers to the use of electronic diaries within the clinic setting and determine outcome differences between patients who used electronic diaries to monitor their progress with summary data feedback and patients who monitored their progress with paper diaries without summary data feedback.

METHODS

One hundred thirty-four (n=134) chronic pain patients were asked to monitor their pain, mood, activity interference, medication use, and pain location on either a paper or electronic diary immediately before each monthly clinic visit for 10 months. Patients and their treating physicians in the electronic diary group (n=67) were able to observe changes in their ratings whereas patients using the paper diaries (n=67) had no feedback about their data entry.

RESULTS

Most participants believed that completing pain diaries was beneficial; yet, only 23% of patients in the experimental condition felt that the data from the electronic diaries improved their care and less than 15% believed that their doctor made a change in their treatment based on the summary diary information.

CONCLUSION

In general, treating physicians were positive about the use of electronic diaries, although they admitted that they did not regularly incorporate the summary data in their treatment decision making because either they forgot or they were too busy. Future studies in understanding barriers to physicians' and patients' use of diary data to impact treatment outcome are needed to improve care for persons with chronic pain.

Contextual and subjective antecedents of smoking in a college student sample

INTRODUCTION

College is a time when individuals are at risk for initiating or increasing their smoking behavior. Little is known, however, about the contexts in which college students smoke. Identifying antecedents to smoking would provide insights into motivation and stimulus control of smoking in this population.

METHOD

In a sample of 50 college student smokers, situational, behavioral, and subjective state variables were compared between prompted interviews (N = 2,095) and participant-initiated smoking interviews (N = 865) using electronic handheld diaries.

RESULTS

The strongest predictors of smoking were recently inhabiting an outside location (odds ratio [OR] = 4.19, p < .001), the presence of others smoking (OR = 3.93, p < .001), and being where smoking was permitted (OR = 3.26, p < .001), indicating situational control over smoking. Less cue control over smoking was found for daily than nondaily smokers. Craving was the most robust subjective antecedent of smoking behavior (OR = 1.32, p < .001).

DISCUSSION

These results suggest that smoking among college students is largely opportunistic, craving is important and may develop early in the progression of smoking, and stimulus control may erode with greater smoking experience.

Feasibility of a daily electronic survey to study prevention behavior with HIV-infected individuals

The daily experiences of persons living with HIV (PLWH) are important but under-studied as predictors of HIV prevention behavior. Ecological momentary assessment (EMA) is an intensive within-subjects data collection method that can be used to examine daily experiences. To determine whether PLWH would participate in EMA, we conducted a feasibility study with 21 PLWH. The method was acceptable to men and women from diverse backgrounds, with 81% (17/21) completing 2 months of daily surveys, and 67% (14/21) completing 6 months. Measures were completed on 72% of study days. Only 6% of records had missing data. Daily survey completion decreased over time. Participants reported that EMA was easy and did not influence their behaviors. Results suggest EMA is feasible with PLWH.

Affect regulation, social context, and sexual intercourse in adolescents

This study examined trajectories of positive and negative affect surrounding penile-vaginal sexual intercourse (sex) in adolescents and explored the influence of companionship on these trajectories. Using a handheld computer, sexually active adolescents (N = 67) reported momentary affect and sex events in response to several random signals each day for 1 week (1,777 reports, 266 sex events). Cubic spline regression analyses showed that positive affect began to increase before sex, peaked at the time sex was reported, and then returned to baseline. Negative affect did not differ from baseline before sex, but decreased following sex. Improvement in affect before and after sex varied according to companionship. Understanding the complex associations of affect, companionship, and sex has implications for interpreting and intervening on adolescent sexual behavior in social context.

Merging health literacy with computer technology: self-managing diet and fluid intake among adult hemodialysis patients

OBJECTIVE

The Dietary Intake Monitoring Application (DIMA) is an electronic dietary self-monitor developed for use on a personal digital assistant (PDA). This paper describes how computer, information, numerical, and visual literacy were considered in development of DIMA.

METHODS

An iterative, participatory design approach was used. Forty individuals receiving hemodialysis at an urban inner-city facility, primarily middle-aged and African American, were recruited.

RESULTS

Computer literacy was considered by assessing abilities to complete traditional/nontraditional PDA tasks. Information literacy was enhanced by including a Universal-Product-Code (UPC) scanner, picture icons for food with no UPC code, voice recorder, and culturally sensitive food icons. Numerical literacy was enhanced by designing DIMA to compute real-time totals that allowed individuals to see their consumption relative to their dietary prescription. Visual literacy was considered by designing the graphical interface to convey intake data over a 24-h period that could be accurately interpreted by patients. Pictorial icons for feedback graphs used objects understood by patients.

PRACTICE IMPLICATIONS

Preliminary data indicate the application is extremely helpful for individuals as they self-monitor their intake. If desired, DIMA could also be used for dietary counseling.

Tobacco, cocaine, and heroin: Craving and use during daily life

BACKGROUND

Relationships among tobacco smoking, tobacco craving, and other drug use and craving may have treatment implications in polydrug-dependent individuals.

METHODS

We conducted the first ecological momentary assessment (EMA) study to investigate how smoking is related to other drug use and craving during daily life. For up to 20 weeks, 106 methadone-maintained outpatients carried PalmPilots (PDAs). They reported their craving, mood, behaviors, environment, and cigarette-smoking status in 2 to 5 random-prompt entries/day and initiated PDA entries when they used cocaine or heroin or had a discrete episode of craving for cocaine or heroin.

RESULTS

Smoking frequency increased linearly with random-prompt ratings of tobacco craving, cocaine craving, and craving for both cocaine and heroin. Smoking frequency was greater during discrete episodes of cocaine use and craving than during random-prompt reports of low craving for cocaine. This pattern was also significant for dual cocaine and heroin use and craving. Smoking and tobacco craving were each considerably reduced during periods of urine-verified abstinence from cocaine, and there was a (nonsignificant) tendency for morning smoking to be especially reduced during those periods.

CONCLUSIONS

This EMA study confirms that smoking and tobacco craving are strongly associated with the use of and craving for cocaine and heroin. Together with prior findings, our data suggest that tobacco and cocaine may each increase craving for (and likelihood of continued use of) themselves and each other. Treatment for tobacco dependence should probably be offered concurrently with (rather than only after) initiation of treatment for other substance-use disorders.

Real-time craving differences between black and white smokers

Black and White smokers may experience aspects of nicotine dependence, including craving, differently. This study used a naturalistic technique, ecological momentary assessment (EMA), to explore differences in craving, mood, expectancy, and smoking enjoyment between Black and White smokers. Participants carried personal digital assistants (PDAs) programmed to obtain multiple daily assessments. Black smokers reported higher craving after smoking and at random assessment times and higher cigarette enjoyment. No differences were found in mood or expectancy. Racial differences in psychological factors related to smoking are explored in the contexts of genetic, sociological, and psychophysiological distinctions. Implications for practice and research are discussed. (Am J Addict 2010;00:1-5).

Do smokers crave cigarettes in some smoking situations more than others? Situational correlates of craving when smoking

INTRODUCTION

Smokers tend to smoke when experiencing craving, but even within smoking occasions, craving may vary. We examine variations in craving when people were smoking in various real-world situations.

METHODS

Using Ecological Momentary Assessment, 394 smokers recorded smoking, craving, and smoking context in real time on electronic diaries over 2 weeks of ad libitum smoking. Assessments occurred immediately prior to smoking. Mixed modeling was used to analyze associations between craving and situational variables.

RESULTS

Craving varied across smoking situations, but the differences were small (<1 on a 0-10 scale). Specifically, craving was higher in smoking situations where smoking was restricted, likely because high craving leads smokers to violate restrictions. Controlling for restrictions, craving was higher when cigarettes were smoked while eating or drinking, were with other people (vs. alone), were in a group of people (vs. other people simply in view), during work (vs. leisure), and during activity (vs. inactivity). In addition, craving was higher for cigarettes smoked early in the day. No differences in craving were observed in relation to drinking alcohol or caffeine (vs. doing anything else), being at work (vs. home), being at a bar or restaurant (vs. all other locations), interacting with others (vs. not interacting), or other people smoking (vs. no others smoking).

DISCUSSION

Even though most craving reports prior to smoking were high, and situations were thus expected to have little influence on craving, results suggest that some cigarettes are craved more than others across different smoking situations, but differences are small.

Ecological momentary assessment (EMA) in studies of substance use

Ecological momentary assessment (EMA) is particularly suitable for studying substance use, because use is episodic and thought to be related to mood and context. This article reviews EMA methods in substance use research, focusing on tobacco and alcohol use and relapse, where EMA has been most applied. Common EMA designs combine event-based reports of substance use with time-based assessments. Approaches to data organization and analysis have been very diverse, particularly regarding their treatment of time. Compliance with signaled assessments is often high. Compliance with recording of substance use appears good but is harder to validate. Treatment applications of EMA are emerging. EMA captures substance use patterns not measured by questionnaires or retrospective data and holds promise for substance use research.

Negative affectivity in smokers applying to smoking cessation clinics: a case-control study

OBJECTIVE

The objective of this study was to assess whether subjects applying to smoking cessation clinics display a higher level of affective symptoms than smokers recruited from the general population.

METHODS

The study was conducted according to a cross-sectional, case-control design. Cases were smokers applying to public smoking cessation clinics for the first time and controls were smokers recruited from the general population. Socio-demographic data and clinical information were collected. Self- (Hospital Anxiety Depression Scale, Beck Depression Inventory, State-Trait Anxiety Inventory) and hetero-administered (Montgomery Asberg Depression Rating Scale, Hamilton Anxiety scale) rating scales were used to assess anxious and depressive symptoms. Nicotine dependence was measured via a self-administered questionnaire (Fagerström Tolerance Questionnaire).

RESULTS

Sixty-eight cases were recruited, individually matched, and compared to controls. Overall, cases had significantly higher scores than controls when the rating scales assessing anxious and depressive symptoms were evaluated.

CONCLUSIONS

Smokers applying to smoking cessation clinics for the first time have a higher level of negative affectivity than smokers from the general population. An evaluation of the level of negative affectivity could be introduced into clinical practice to have a complete assessment of the patient. We propose adding psychological or pharmacological support to complement the smoking cessation program.

How many cigarettes did you smoke? Assessing cigarette consumption by global report, Time-Line Follow-Back, and ecological momentary assessment

OBJECTIVE

This study evaluated and compared several methods of assessing daily cigarette consumption.

DESIGN

Comparison of measures of daily cigarette consumption from several sources, from 232 smokers entering a smoking cessation program.

MAIN OUTCOME MEASURES

Global reports of average smoking, Time-Line Follow-Back (TLFB) recall for the week preceding the study (premonitoring TLFB), 2 weeks' cigarette recordings using electronic diaries and ecological momentary assessment (EMA), and TLFB recall of smoking during EMA (monitored TLFB).

RESULTS

Global reports and premonitoring TLFB showed severe digit bias: six times as many values as expected were rounded at 10. Monitored TLFB also showed substantial digit bias (four times). EMA data showed none. EMA averaged 2.6 cigarettes lower than monitored TLFB, but exceeded TLFB on 32% of days. Across days, EMA and TLFB only correlated 0.29. Daily variations in TLFB did not correlate with variations in carbon monoxide (CO) measures taken on 3 days, but EMA measures did; among participants whose CO varied, r = .69. CO correlated with EMA cigarettes recorded in the preceding 2 hours, suggesting timely recording of cigarettes.

CONCLUSION

TLFB measures are limited for precise assessment of cigarette consumption. EMA measures appear to be useful for tracking smoking, and likely other health-relevant events.

Cocaine craving and use during daily life

RATIONALE

Craving is often assumed to cause ongoing drug use and relapse and is a major focus of addiction research. However, its relationship to drug use has not been adequately documented.

OBJECTIVES

The aim of this study was to investigate the relationship between craving and drug use in real time and in the daily living environments of drug users.

METHODS

In a prospective, longitudinal, cohort design (ecological momentary assessment), 112 cocaine-abusing individuals in methadone maintenance treatment rated their craving and mood at random times (two to five times daily, prompted by electronic diaries) as they went about their everyday activities. They also initiated an electronic diary entry each time they used cocaine. Drug use was monitored by thrice-weekly urine testing.

RESULTS

During periods of urine-verified cocaine use, ratings of cocaine craving increased across the day and were higher than during periods of urine-verified abstinence. During the 5 h prior to cocaine use, ratings of craving significantly increased. These patterns were not seen in ratings of heroin craving or mood (e.g., feeling happy or bored).

CONCLUSIONS

Cocaine craving is tightly coupled to cocaine use in users' normal environments. Our findings provide previously unavailable support for a relationship that has been seriously questioned in some theoretical accounts. We discuss what steps will be needed to determine whether craving causes use.

A method comparison study of timeline followback and ecological momentary assessment of daily cigarette consumption

INTRODUCTION

Uncertainty exists about how best to measure daily cigarette consumption. Two common measures are timeline followback (TLFB), which involves structured, prompted recall, and ecological momentary assessment (EMA), which involves recording consumption, as it occurs, on a handheld electronic device.

METHODS

We evaluated the agreement between TLFB and EMA measures collected for 14 days prior to the target quit date from 236 smokers in a smoking cessation program. We performed a Bland-Altman analysis to assess agreement of TLFB and EMA using a regression-based model that allows for a nonuniform difference between methods and limits of agreement that can vary with the number of cigarettes smoked.

RESULTS

For pairs of measurements taken on the same smoker, TLFB counts were on average 3.2 cigarettes higher than EMA counts; this difference increased for larger numbers of cigarettes. Using a model that allows for variable limits of agreement, the width of the 95% interval ranged from 8.7 to 61.8 cigarettes, with an average of 26.4 cigarettes. Variation between the methods increased substantially for larger cigarette counts, leading to wider limits and poorer agreement for heavy smokers.

DISCUSSION

Throughout the measurement range, the estimated limits of agreement were far wider than the limits of clinical significance, defined a priori to be 20% of the number of cigarettes smoked. We conclude that TLFB and EMA cannot be considered equivalent for the assessment of daily cigarette consumption, especially for heavy smokers.

Smokers' expectancies for abstinence: preliminary results from focus groups

Smokers' expectancies regarding the effects of cigarette use are powerful predictors of smoking motivation and behavior. However, studies have not investigated the consequences that smokers expect when they attempt to quit smoking: abstinence-related expectancies. The primary goal of this qualitative study was to gain initial insight into smokers' expectancies for abstinence. Eight focus groups were conducted with 30 smokers diverse with respect to age, gender, and ethnoracial background. Content analyses indicated that smokers anticipate a variety of outcomes from abstinence. The most frequently reported expectancies included pharmacologic withdrawal symptoms, behavioral withdrawal symptoms, decreased monetary expense, and immediate improvement of certain aspects of physical functioning and health. Additional expectancies concerned weight gain, improved attractiveness, enhanced social functioning/self-esteem, long-term health outcomes, and loss of relationships. Finally, a number of relatively unheralded expectancies were revealed. These involved nicotine replacement therapy effectiveness, alcohol and other drug use, cue reactivity, cessation-related social support, aversion to smoking, and "political process" implications. This study provides a preliminary step in understanding smokers' expectancies for abstinence from cigarettes.

Development of a hand-held computer platform for real-time behavioral assessment of physicians and nurses

We developed a hand-held data collection tool to facilitate real-time collection of data on the factors that affect hospital staff performance. To assure high-yield of data from busy clinicians, the design objectives included low response burden, the ability to collect complex real-time data in dynamic work environments, and automated data integration. Iterative user-centered design of custom interfaces resulted in a dynamic intuitive platform where branching logic was applied to present a series of survey questions dependent on the participant's responses. Over a 12-month period, 304 inpatient physicians and nurses completed (with minimal initial training) a total of 11,381 survey responses. For randomly timed repeated survey prompts, complete (73%) or partial (12%) responses were obtained in a median time of 96s.

Laboratory-based, cue-elicited craving and cue reactivity as predictors of naturally occurring smoking behavior

Cigarette craving, one hallmark sign of nicotine dependence, is often measured in laboratory settings using cue reactivity methods. How lab measures of cue reactivity relate to real world smoking behavior is unclear, particularly among non-treatment seeking smokers. Within a larger study of hormonal effects on cue reactivity (N=78), we examined the predictive relationship of cue reactivity to smoking, each measured in several ways. Results indicated that cue-evoked craving in response to stressful imagery, and to a lesser extent, in vivo smoking cues, significantly predicted smoking behavior during the week following testing. However, this predictive relationship was absent upon controlling for reactivity to neutral cues. Nicotine dependence may moderate the relationship between cue reactivity and actual smoking, such that this predictive relationship is less robust among highly dependent smokers than among smokers low in nicotine dependence. The question of whether cue-elicited craving predicts smoking among smokers not in treatment is best answered with a qualified yes, depending on how craving is manipulated and measured. Our findings highlight important methodological and theoretical considerations for cue reactivity research.

Generalized craving, self-report of arousal, and cue reactivity after brief abstinence

INTRODUCTION

Numerous studies report smokers' increased craving and physiological arousal when exposed to cigarette stimuli. These responses are attributed to learning processes (e.g., classical conditioning) and are associated with motivational factors that maintain nicotine dependence. However, much less is known about the degree to which these responses are maintained or diminished during quitting.

METHODS

Treatment-seeking smokers (N = 104) were randomly assigned to continue smoking or to enter a 2-week treatment program. Abstainers (n = 25) were continuously abstinent for 14-17 days at the time of testing. Control subjects (n = 38) continued to smoke at their usual rate. Participants who were assigned to treatment but resumed smoking during the study (n = 41) were considered to be relapsers. Approximately 2 weeks after baseline measurements, abstainers and controls viewed a series of neutral (n = 12) and cigarette (n = 12) pictures, rating them for craving and arousal (feelings of calm vs. excitement).

RESULTS

Non-cued craving (measured during exposure to neutral cues) was diminished in abstaining smokers. However, cigarette cues produced craving increases of the same magnitude in both abstainers and controls, showing that these cues still had evocative power for both groups. Abstaining smokers, who were not physiologically monitored, had lower self-reports of arousal to cigarette pictures than did controls, but the groups did not differ in arousal to neutral pictures.

DISCUSSION

These findings suggest that the foundations of cue-induced craving, generalized craving, and physiological arousal associated with craving may arise from separate processes.

Changing age-specific patterns of cigarette consumption in the United States, 1992-2002: association with smoke-free homes and state-level tobacco control activity

INTRODUCTION

During the 1990s, both prevalence and average cigarette consumption declined in the United States, but age-specific changes have not been reported.

METHOD

All four of the nationally and state representative U.S. Current Population Surveys-Tobacco Use Supplements from 1991-2002 (n = 542,470) were analyzed for trends in cigarette consumption among smokers in three age groups: 18-29, 30-44, and 45-64 years. A strength of tobacco control index ranking state of residence was added and weighted logistic regression analyses undertaken.

RESULTS

Over the decade, both prevalence and average consumption declined. Moderate-heavy smoking (> or =15 cigarettes/day [CPD]) prevalence fell strongly over the period in all three age groups. For those aged > or =30 years, this reduction was accompanied by a similar drop in total smoking prevalence. For those aged 18-29 years, this reduction was associated with an increase in very light smoking (<5 CPD; 12% daily and 88% intermittent smokers) to 22.5% of current smokers with a much smaller reduction in prevalence. Smoke-free homes more than doubled in each age group and mediated the increase in very light smoking levels. Smoke-free workplaces and the strength of tobacco control in the state were also important predictors. Very light smoking was particularly prevalent among college students and graduates.

DISCUSSION

The marked reduction in prevalence of moderate-heavy smoking across age groups should translate into a reduced population risk of smoking-related disease in the near term. That this reduction is offset by an increase in light and intermittent smoking in young adults suggests the effectiveness of tobacco industry marketing and needs further research.

Smoking is associated with worse mood on stressful days: results from a national diary study

BACKGROUND

Many smokers report smoking because it helps them modulate their negative affect (NA). The stress induction model of smoking suggests, however, that smoking causes stress and concomitant NA. Empirical support for the stress induction model has primarily derived from retrospective reports and experimental manipulations with non-representative samples of smokers. Moreover, prior studies have typically not considered contextual factors (e.g., daily stressors) that may impact the smoking-NA relationship.

PURPOSE

The aim of this study was to assess the stress induction model of smoking using a prospective design in a nationally representative sample of smokers while simultaneously examining the impact of daily stressors on the relationship between smoking and NA. We hypothesized that smoking and NA would be positively related, and this relationship would be intensified by exposure to daily stressors.

METHODS

A national sample of middle-aged smokers (N = 256) were called on eight consecutive evenings to assess stressor exposure and intensity. Participants also reported on their daily NA and indicated the number of cigarettes they smoked. Analyses were conducted using hierarchical linear modeling to determine the relationship between daily smoking, NA, and stress.

RESULTS

Smoking more than usual was associated with increased NA on days when respondents were exposed to any stressors. Smoking more than usual had no effect on NA on days when no stressors were encountered. Moreover, the moderating effect of stressor exposure remained significant even after controlling for the number and intensity of daily stressors reported.

CONCLUSIONS

While smokers report that smoking alleviates their NA, our study suggests that the exact opposite may occur, particularly on stressful days. When smokers smoke more than usual on days when the encounter stress, they are likely to feel emotionally worse off.

Nicotine differentially inhibits the acoustic startle reflex in African American and Caucasian American smokers

Research suggests that there are racial disparities in smoking behaviors, cessation rates, mortality, and morbidity. However, little is known regarding racial differences in affect regulation by smoking. The purpose of this study was to examine racial differences in the effects of nicotine deprivation and administration on smokers' startle responding to smoking and affective cues. 104 African American (AA) and Caucasian American (CA) smokers completed 4 laboratory sessions crossing nicotine deprivation (12-hour deprived vs. nondeprived) with nicotine nasal spray (active vs. placebo). Participants viewed affective (positive, neutral, and negative) and smoking slides while startle probes were administered. The results showed that relative to placebo, AA smokers given nicotine spray exhibited significantly lower startle responses when they were exposed to smoking cues and CA smokers given nicotine spray exhibited significantly lower startle responses when they were exposed to negative and neutral cues. Although nicotine suppresses startle responding in both AA and CA smokers, the effect is modulated by different cue conditions, suggesting that there may be racial differences in components of smoking motivation.

Ecological momentary assessment of adolescent smoking cessation: a feasibility study

Attempts to quit smoking by adolescents typically fail, even when aided by psychosocial and pharmacological treatments. Gaining a better understanding of the process of smoking cessation and relapse in this population could lead to improved treatments and increases in cessation rates. Ecological momentary assessment (EMA) has been used to describe the relapse process among adults, but not among adolescents. This study examined the feasibility of using EMA to examine relapse among adolescent smokers. Participants (N = 13) used a hand-held computer for 3 weeks to report on their smoking behavior, affect state, and exposure to smoking cues during a quit attempt (7 days prequit, 14 days postquit). All of the participants recorded a quit attempt and at least one lapse during the monitoring interval. Compliance with the protocol was generally high but decreased slightly over time. As with adults, evidence indicated that lapses were associated with craving, negative affect, and smoking cues. These data support the feasibility and potential value of using EMA with adolescent smokers.

Internet delivered support for tobacco control in dental practice: randomized controlled trial

Background

The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized.

Objective

To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings.

Methods

Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention.

Results

Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices’ mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK.

Conclusion

This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit.

Trial Registration

clinicaltrials.gov NCT00627185; http://clinicaltrials.gov/ct2/show/NCT00627185 (Archived by WebCite at http://www.webcitation.org/5c5Kugvzj)

Evidence-based assessment of adherence to medical treatments in pediatric psychology

OBJECTIVES

Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

METHODS

This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

RESULTS

Ten measures met the "well-established" evidence-based (EBA) criteria.

CONCLUSIONS

Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the "real time" behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

Ecological momentary assessment

Assessment in clinical psychology typically relies on global retrospective self-reports collected at research or clinic visits, which are limited by recall bias and are not well suited to address how behavior changes over time and across contexts. Ecological momentary assessment (EMA) involves repeated sampling of subjects' current behaviors and experiences in real time, in subjects' natural environments. EMA aims to minimize recall bias, maximize ecological validity, and allow study of microprocesses that influence behavior in real-world contexts. EMA studies assess particular events in subjects' lives or assess subjects at periodic intervals, often by random time sampling, using technologies ranging from written diaries and telephones to electronic diaries and physiological sensors. We discuss the rationale for EMA, EMA designs, methodological and practical issues, and comparisons of EMA and recall data. EMA holds unique promise to advance the science and practice of clinical psychology by shedding light on the dynamics of behavior in real-world settings.

What underlies appraisals? Experimentally testing a Knowledge-and-Appraisal Model of Personality Architecture among smokers contemplating high-risk situations

We tested a theoretical model of personality structures underlying patterns of intra-individual variability in contextualized appraisals. The KAPA (Knowledge-and-Appraisal Personality Architecture) model was tested experimentally among smokers appraising their efficacy to resist the urge to smoke in high-risk situations. In a novel design, we assessed self-knowledge and situational beliefs idiographically and employed cognitive priming to manipulate the accessibility of self-knowledge experimentally. The results confirmed the unique KAPA-model prediction that priming would affect appraisals in a contextualized manner. Priming positively valenced self-knowledge enhanced self-efficacy appraisals specifically within that subset of situations that were relevant to the primed knowledge. The results were consistent with the hypothesis that systems of self- and situational knowledge underlie consistency and variability in appraisals.

Does delayed measurement affect patient reports of provider performance? Implications for performance measurement of medical assistance with tobacco cessation: a Dental PBRN study

Background:

We compared two methods of measuring provider performance of tobacco control activities: immediate "exit cards" versus delayed telephone follow-up surveys. Current standards, e.g. HEDIS, use delayed patient measures that may over or under-estimate overall performance.

Methods:

Patients completed exit cards in 60 dental practices immediately after a visit to measure whether the provider "asked" about tobacco use, and "advised" the patient to quit. One to six months later patients were asked the same questions by telephone survey. Using the exit cards as the standard, we quantified performance and calculated sensitivity (agreement of those responding yes on telephone surveys compared with exit cards) and specificity (agreement of those responding no) of the delayed measurement.

Results:

Among 150 patients, 21% reporting being asked about tobacco use on the exit cards and 30% reporting being asked in the delayed surveys. The sensitivity and specificity were 50% and 75%, respectively. Similarly, among 182 tobacco users, 38% reported being advised to quit on the exit cards and this increased to 51% on the delayed surveys. The sensitivity and specificity were 75% and 64%, respectively. Increasing the delay from the visit to the telephone survey resulted in increasing disagreement.

Conclusion:

Patient reports differed considerably in immediate versus delayed measures. These results have important implications because they suggest that our delayed measures may over-estimate performance. The immediate exit cards should be included in the armamentarium of tools for measuring providers' performance of tobacco control, and perhaps other service delivery.

Gender differences in immediate antecedents of ad lib cigarette smoking in smokers with and without posttraumatic stress disorder: a preliminary report

Using ambulatory methods for monitoring, this study investigated gender differences regarding the association between smoking and situational cues in 63 smokers with posttraumatic stress disorder (PTSD) and 32 smokers without PTSD. Smokers were instructed to complete a diary entry each time an ambulatory blood pressure monitor took a reading and each time they prepared to smoke. Generalized estimating equations contrasted 682 smoking and 444 nonsmoking situations by group status. For all smokers, ad lib smoking was strongly related to craving. For women with PTSD, ad lib smoking was strongly related to total PTSD symptoms, PTSD reexperiencing symptoms, and PTSD hyperarousal symptoms. For men with PTSD, ad lib smoking was significantly related to negative affect, PTSD reexperiencing symptoms, restlessness, and worry. No other mood antecedents were significant for women or men smokers without PTSD. These results are consistent with previous studies documenting gender differences in smoking behavior, and underscore the importance of examining gender differences in psychiatric samples.

Evaluating the utility of administering a reaction time task in an ecological momentary assessment study

RATIONALE

Cognitive processes underlying drug use have typically been assessed in laboratory settings. More detailed and ecologically valid data may be possible if assessments were conducted in an ecological momentary assessment (EMA) setting.

OBJECTIVES

We evaluated the feasibility and utility of administering a reaction time task on a hand-held computer (personal digital assistant, PDA) in an EMA setting.

MATERIALS AND METHODS

Twenty-two smokers and 22 non-smokers carried around the PDA for 1 week as they went about their daily lives. They were beeped at random times four times per day (random assessments, RAs). Participants were also instructed to press an "anxiety assessment" (AA) button on the PDA whenever they felt suddenly anxious. At each assessment (RA, AA), participants responded to items assessing subjective, pharmacological, and contextual variables, and subsequently completed a Stroop task (classic-Stroop, emotional-Stroop, or smoking-Stroop task).

RESULTS

Participants responded to 81.2% of RAs, completed assessments in an average of 4.44 min, reported no interruptions on the majority of assessments (62.4%), and produced data with adequate reliability. Using generalized estimating equation (GEE) analyses, age was associated with the classic-Stroop effect, state anxiety was associated with the emotional-Stroop effect, and Fagerstrom Test for Nicotine Dependence scores were associated with the smoking-Stroop effect.

CONCLUSIONS

The study provided evidence for the feasibility and utility of the approach.

Feasibility of Ecological Momentary Assessment Using Cellular Telephones in Methamphetamine Dependent Subjects

Background

Predictors of relapse to methamphetamine use are poorly understood. State variables may play an important role in relapse, but they have been difficult to measure at frequent intervals in outpatients.

Methods

We conducted a feasibility study of the use of cellular telephones to collect state variable data from outpatients. Six subjects in treatment for methamphetamine dependence were called three times per weekday for approximately seven weeks. Seven questionnaires were administered that assessed craving, stress, affect and current type of location and social environment.

Results

395/606 (65%) of calls attempted were completed. The mean time to complete each call was 4.9 (s.d. 1.8) minutes and the mean time to complete each item was 8.4 (s.d. 4.8) seconds. Subjects rated the acceptability of the procedures as good. All six cellular phones and battery chargers were returned undamaged.

Conclusion

Cellular telephones are a feasible method for collecting state data from methamphetamine dependent outpatients.

The effect of retail cigarette pack displays on impulse purchase

AIMS

To assess the extent to which point-of purchase (POP) cigarette displays stimulate impulse purchases.

DESIGN

Telephone-administered population survey.

SETTING

Victoria, Australia.

PARTICIPANTS

A total of 2996 adults, among whom 526 smoked factory-made cigarettes and 67 were recent quitters (quit in the past 12 months).

MEASUREMENTS

Reported cigarette purchase behaviour; perceived effect on smoking of removing cigarettes from view in retail outlets; reported urges to buy cigarettes as a result of seeing the cigarette display.

FINDINGS

When shopping for items other than cigarettes, 25.2% of smokers purchased cigarettes at least sometimes on impulse as a result of seeing the cigarette display. Thirty-eight per cent of smokers who had tried to quit in the past 12 months and 33.9% of recent quitters experienced an urge to buy cigarettes as a result of seeing the retail cigarette display. One in five smokers trying to quit and one in eight recent quitters avoided stores where they usually bought cigarettes in case they might be tempted to purchase them. Many smokers (31.4%) thought the removal of cigarette displays from stores would make it easier for them to quit.

CONCLUSIONS

POP cigarette displays act as cues to smoke, even among those not explicitly intending to buy cigarettes, and those trying to avoid smoking. Effective POP marketing restrictions should encompass cigarette displays.