An exploratory examination of the mechanisms through which pre-quit patch use aids smoking cessation

Evaluating Declines in Compliance With Ecological Momentary Assessment in Longitudinal Health Behavior Research: Analyses From a Clinical Trial

BACKGROUND

Ecological momentary assessment (EMA) is increasingly used to evaluate behavioral health processes over extended time periods. The validity of EMA for providing representative, real-world data with high temporal precision is threatened to the extent that EMA compliance drops over time.

OBJECTIVE

This research builds on prior short-term studies by evaluating the time course of EMA compliance over 9 weeks and examines predictors of weekly compliance rates among cigarette-using adults.

METHODS

A total of 257 daily cigarette-using adults participating in a randomized controlled trial for smoking cessation completed daily smartphone EMA assessments, including 1 scheduled morning assessment and 4 random assessments per day. Weekly EMA compliance was calculated and multilevel modeling assessed the rate of change in compliance over the 9-week assessment period. Participant and study characteristics were examined as predictors of overall compliance and changes in compliance rates over time.

RESULTS

Compliance was higher for scheduled morning assessments (86%) than for random assessments (58%) at the beginning of the EMA period (P<.001). EMA compliance declined linearly across weeks, and the rate of decline was greater for morning assessments (2% per week) than for random assessments (1% per week; P<.001). Declines in compliance were stronger for younger participants (P<.001), participants who were employed full-time (P=.03), and participants who subsequently dropped out of the study (P<.001). Overall compliance was higher among White participants compared to Black or African American participants (P=.001).

CONCLUSIONS

This study suggests that EMA compliance declines linearly but modestly across lengthy EMA protocols. In general, these data support the validity of EMA for tracking health behavior and hypothesized treatment mechanisms over the course of several months. Future work should target improving compliance among subgroups of participants and investigate the extent to which rapid declines in EMA compliance might prove useful for triggering interventions to prevent study dropout.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03262662; https://clinicaltrials.gov/ct2/show/NCT03262662.

The influence of culture and close others on the effectiveness of (self)-persuasion

Although self-persuasion was shown to be more effective than direct persuasion in changing attitudes and intentions, its effectiveness in different cultures remains unclear. Furthermore, research suggests that Eastern individuals tend to incorporate close others in the self to a larger extent than Western individuals. Combining both lines of research, the current studies examined whether thinking of a close other would influence the effectiveness of (self)-persuasion across cultures. Two parallel studies were conducted. U.S. participants (n_study 1 = 195; n_study 2 = 292) and Chinese participants (n_study 1 = 187; n_study 2 = 313) reported their initial attitudes and intentions toward five target behaviors prior to either think of a specific close other or not. Subsequently, they were randomly assigned to receive either a self-persuasion or a direct persuasion task. Specifically, the self-persuasion task led participants to generate own arguments or arguments that they think the close other would give; the direct persuasion task led participants to read given arguments or imagine that the arguments were from the close other. In the end, all participants reported their attitudes and intentions again after doing the persuasion tasks. The moderation effect of culture was only found in Study 1, such that direct persuasion worked more effectively in Chinese participants than self-persuasion, whereas the effectiveness of the two persuasive techniques did not differ in U.S. participants. In both studies, thinking of a close other was not found to influence the effectiveness of (self-)persuasion across cultures. Possible explanations and future research directions were discussed.

Pre-quit nicotine decreases nicotine self-administration and attenuates cue- and drug-induced reinstatement

BACKGROUND

Administration of smoking cessation medications in anticipation of a nominated quit date can promote abstinence. How this occurs is not widely understood, but may be due to the disruption of contingencies between smoking behaviour and acute drug effects.

AIMS

The aim of this study was to explore this relationship, we examined the effect of pre-quit nicotine replacement therapy on susceptibility to relapse in an animal model of nicotine dependence.

METHODS

Rats were trained to intravenously self-administer nicotine across 20 days. Continuous low-dose nicotine was administered via a mini-osmotic pump either across the last 7 days of self-administration and across 6 days of extinction, or across extinction only. Cue- and drug-induced reinstatements of responding were then measured with mini-pumps retained, the day after mini-pump removal or one week later.

RESULTS

Pre-quit nicotine administration markedly reduced self-administration across the last days of training as the response, and its associated cues, no longer reliably predicted an acute drug effect. Pre-quit, but not post-quit, nicotine administration significantly attenuated cue-induced reinstatement once mini-pumps were removed, indicating that the contingency disruption across training reduced the conditioned reinforcing properties of the cue at test. Both pre-quit and post-quit nicotine attenuated nicotine-primed reinstatement.

CONCLUSIONS

Together these results suggest that administration of a nicotine replacement prior to a nominated quit date may enhance resistance to relapse via disruption of the contingency between a response, its associated cues, and a rewarding nicotine effect.

A Randomized Clinical Trial of Nicotine Preloading for Smoking Cessation in People with Posttraumatic Stress Disorder

OBJECTIVE

The aim of this research was to determine whether augmenting standard smoking cessation treatment by wearing an active nicotine patch before the smoking quit date improves rates of smoking cessation in individuals with posttraumatic stress disorder (PTSD) and to explore mechanisms of treatment response such as decreased cigarette craving and symptom relief from smoking.

METHODS

This was a double-blind parallel randomized controlled trial in 81 people with PTSD who smoked cigarettes. Participants were recruited from Veterans Affairs outpatient clinics and flyers in the community. Participants provided ecological momentary assessments (EMAs) of PTSD symptoms, smoking withdrawal symptoms, and cravings before and after smoking a cigarette during one week of ad lib smoking and then three weeks of either a nicotine patch (n = 37) or placebo patch (n = 44) preceding the quit date. All participants received standard pharmacotherapy and behavioral treatment for smoking cessation after the quit date. To test the efficacy of nicotine patch preloading for engaging proposed treatment targets during the pre-quit phases, we used multilevel models to compare post-smoking changes in symptoms and cravings during the preloading phases to post-smoking changes reported during the ad lib smoking phase.

RESULTS

There was no significant difference in quit rates across the two conditions on the primary outcome of seven-day point prevalence smoking abstinence bioverified with breath carbon monoxide at six weeks post-quit date. In a multivariable multilevel model pre- to post-cigarette changes in PTSD symptom clusters, smoking withdrawal symptoms, and cravings, there was a significant interaction between treatment phase and condition. Relative to participants in the placebo condition, participants in the nicotine patch condition experienced diminished relief from PTSD reexperiencing symptoms, smoking withdrawal symptoms, and cigarette craving after smoking a cigarette.

CONCLUSIONS

Relative to placebo patch preloading, nicotine patch preloading diminished the reinforcing effects of smoking cigarettes. However, the low quit rates in both conditions suggest that nicotine patch preloading is not a sufficiently intensive treatment for achieving smoking cessation in people with PTSD.

TRIAL REGISTRATION

clinicaltrials.gov: NCT00625131.

Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption

Background

Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit.

Purpose

Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings.

Methods

Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking.

Results

Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy.

Conclusions

Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.

The effect of varenicline and nicotine patch on smoking rate and satisfaction with smoking: an examination of the mechanism of action of two pre-quit pharmacotherapies

OBJECTIVES

In recent years, there has been growing research interest in using nicotine replacement medications to aid smoking reduction prior to a quit attempt. Gaining a better understanding of how treatments influence smoking reduction may allow for better tailoring of treatments and, ultimately, better cessation outcomes. The objective of the current study was to test the effects of the pre-quit use of varenicline and nicotine patch on smoking rate and satisfaction with smoking.

METHODS

All participants were required to attend up to five study visit sections. Participants (n = 213) who were interested in quitting were randomised (open-label) to receive either pre-quit patch or varenicline (both treatments started 2 weeks prior to an assigned quit day, followed by 10 weeks post-quit) or standard patch (10 weeks starting from an assigned quit day). Participants used modified smartphones to monitor their smoking in real time for 4 weeks.

RESULTS

Participants in the two pre-quit treatment groups reported significant reductions in both their satisfaction with smoking (p < 0.001) and smoking rate (p < 0.001) from baseline to the end of pre-quit period; participants in the standard patch group did not. The observed reduction of smoking rate was associated with the satisfaction with smoking (p < 0.01), although the mediation effect of satisfaction was small.

CONCLUSIONS

Pre-quit treatment caused reductions in satisfaction with smoking and smoking rate. Satisfaction was associated with changes in smoking rate, but the relationship was weak. As such, monitoring reductions in satisfaction do not appear to be a viable method of evaluating responsiveness to treatment.

Evaluating Nicotine Craving, Withdrawal, and Substance Use as Mediators of Smoking Cessation in Cocaine- and Methamphetamine-Dependent Patients

INTRODUCTION

Smoking is highly prevalent in substance dependence, but smoking-cessation treatment (SCT) is more challenging in this population. To increase the success of smoking cessation services, it is important to understand potential therapeutic targets like nicotine craving that have meaningful but highly variable relationships with smoking outcomes. This study characterized the presence, magnitude, and specificity of nicotine craving as a mediator of the relationship between SCT and smoking abstinence in the context of stimulant-dependence treatment.

METHODS

This study was a secondary analysis of a randomized, 10-week trial conducted at 12 outpatient SUD treatment programs. Adults with cocaine and/or methamphetamine dependence (N = 538) were randomized to SUD treatment as usual (TAU) or TAU+SCT. Participants reported nicotine craving, nicotine withdrawal symptoms, and substance use in the week following a uniform quit attempt of the TAU+SCT group, and self-reported smoking 7-day point prevalence abstinence (verified by carbon monoxide) at end-of-treatment.

RESULTS

Bootstrapped regression models indicated that, as expected, nicotine craving following a quit attempt mediated the relationship between SCT and end-of-treatment smoking point prevalence abstinence (mediation effect = 0.09, 95% CI = 0.04% to 0.14%, P < .05, 14% of total effect). Nicotine withdrawal symptoms and substance use were not significant mediators (Ps > .05, <1% of total effect). This pattern held for separate examinations of cocaine and methamphetamine dependence.

CONCLUSIONS

Nicotine craving accounts for a small but meaningful portion of the relationship between smoking-cessation treatment and smoking abstinence during SUD treatment. Nicotine craving following a quit attempt may be a useful therapeutic target for increasing the effectiveness of smoking-cessation treatment in substance dependence.

Higher stimulus control is associated with less cigarette intake in daily smokers

It is well established that environmental stimuli influence smoking in light, and to a lesser degree, heavy smokers. A 2-factor model of dependence suggests that the influence of stimulus control is masked among heavier smokers who primarily smoke for nicotine maintenance. The current study aimed to assess the influence of stimulus control across a range of moderate to heavy daily smokers. Furthermore, as local tobacco control policies may change the role of stimulus control, the study aimed to replicate previous U.S. findings on stimulus control in an Australian setting marked by strong tobacco control policies. In 2 Ecological Momentary Assessment studies, 420 participants monitored antecedents of smoking and nonsmoking situations. In a set of idiographic logistic regression analyses, situational antecedents were used to predict smoking occasions within each individual's data. Linear regression analysis was used to test for the association between stimulus control and smoking rate, and to test for differences between the 2 samples. Daily smokers' smoking was under considerable stimulus control, which was weaker at higher smoking rates. Overall, there was greater stimulus control in the Australian sample. Daily smokers also experience a degree of stimulus control, which is less influential in heavier smokers.

Comparative effectiveness of motivation phase intervention components for use with smokers unwilling to quit: a factorial screening experiment

AIMS

To screen promising intervention components designed to reduce smoking and promote abstinence in smokers initially unwilling to quit.

DESIGN

A balanced, four-factor, randomized factorial experiment.

SETTING

Eleven primary care clinics in southern Wisconsin, USA.

PARTICIPANTS

A total of 517 adult smokers (63.4% women, 91.1% white) recruited during primary care visits who were willing to reduce their smoking but not quit.

INTERVENTIONS

Four factors contrasted intervention components designed to reduce smoking and promote abstinence: (1) nicotine patch versus none; (2) nicotine gum versus none; (3) motivational interviewing (MI) versus none; and (4) behavioral reduction counseling (BR) versus none. Participants could request cessation treatment at any point during the study.

MEASUREMENTS

The primary outcome was percentage change in cigarettes smoked per day at 26 weeks post-study enrollment; the secondary outcomes were percentage change at 12 weeks and point-prevalence abstinence at 12 and 26 weeks post-study enrollment.

FINDINGS

There were few main effects, but a significant four-way interaction at 26 weeks post-study enrollment (P = 0.01, β = 0.12) revealed relatively large smoking reductions by two component combinations: nicotine gum combined with BR and BR combined with MI. Further, BR improved 12-week abstinence rates (P = 0.04), and nicotine gum, when used without MI, increased 26-week abstinence after a subsequent aided quit attempt (P = 0.01).

CONCLUSIONS

Motivation-phase nicotine gum and behavioral reduction counseling are promising intervention components for smokers who are initially unwilling to quit.

Examination of the mechanism of action of two pre-quit pharmacotherapies for smoking cessation

Background

There is substantial scope for improvement in the current arsenal of smoking cessation methods and techniques: even when front-line cessation treatments are utilized, smokers are still more likely to fail than to succeed. Studies testing the incremental benefit of using nicotine patch for 1–4 weeks prior to quitting have shown pre-quit nicotine patch use produces a robust incremental improvement over standard post-quit patch treatment. The primary objective of the current study is to test the mechanism of action of two pre-quit smoking cessation medications—varenicline and nicotine patch—in order to learn how best to optimize these pre-quit treatments.

Methods/Design

The study is a three group, randomized, open-label controlled clinical trial. Participants (n = 216 interested quitters) will be randomized to receive standard patch treatment (10 weeks of patch starting from a designated quit day), pre-quit patch treatment (two weeks of patch treatment prior to a quit day, followed by 10 weeks post-quit treatment) or varenicline (starting two weeks prior to quit day followed by 10 weeks post-quit). Participants will use study-specific modified smart-phones to monitor their smoking, withdrawal symptoms, craving, mood and social situations in near real-time over four weeks; two weeks prior to an assigned quit date and two weeks after this date. Smoking and abstinence will be assessed at regular study visits and biochemically verified.

Discussion

Understanding how nicotine patches and varenicline influence abstinence may allow for better tailoring of these treatments to individual smokers.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12614000329662 (Registered: 27 March 2014).

Does the Magnitude of Reduction in Cigarettes Per Day Predict Smoking Cessation? A Qualitative Review

INTRODUCTION

Reduction in cigarettes per day (CPD) aided by nicotine replacement therapy (NRT) increases cessation in smokers; however, it is unclear whether this is due to use of NRT or reduction per se. If the latter, a greater magnitude of reduction in CPD should increase the odds of cessation.

METHODS

The authors searched PubMed, Cochrane, PsychINFO, http://clinicaltrials.gov and their personal libraries for studies on smoking reduction. Seven of the 76 (9%) identified intervention trials and four of 28 naturalistic studies (14%) reported on the magnitude of reduction in relation to the odds of cessation.

RESULTS

Five of the seven intervention trials and three of the four naturalistic observational (cohort) studies found that increased reduction in CPD was associated with increased cessation. The intervention trials that reported effect sizes found that every 1% decrease in CPD or carbon monoxide was associated with a 3% to 4% increase in the odds of cessation. The naturalistic studies found that ordinal (eg, quartile) increases in participants' magnitude of reduction in CPD were associated with 50% to 290% increases in the odds of cessation. All of the naturalistic studies and four of the intervention trials included covariates; however, reduction's association with cessation could still be due to its association with NRT use or motivation.

CONCLUSION

Although prospective prediction does not necessarily indicate causality, our findings suggest reduction in CPD is a mechanism of increased cessation in prior NRT-aided reduction studies.