Aversive smoking therapies: a conditioning analysis of therapeutic effectiveness

Hypothalamic pituitary adrenal and autonomic nervous system biomarkers of stress and tobacco relapse: Review of the research

Tobacco smoking is a risk factor for countless diseases, and smoking relapse remains a major public health concern. Subjective reports of stress by smokers are a common theme for relapse, however, the role of objective stress-related biomarkers in predicting tobacco relapse risk has been less studied. The aim of this manuscript was to review existing literature on the connection between biomarkers of stress and smoking relapse. Overall, trends indicate that blunted hypothalamic-pituitary-adrenal (HPA) responses to acute stress, larger reductions in HPA biomarkers during the initial days of abstinence during cessation (compared to pre-cessation levels), and exaggerated autonomic responses to stress predict increased risk of relapse. In addition, successful cessation is followed by changes in stress biomarkers (e.g., reductions in cortisol and heart rate, HR). This review also identifies potential modifiers, such as methodological differences, biological sex, and chronic stress, to account for heterogeneity of findings within and across studies. In addition, we identify gaps in the literature and suggest future research directions focusing on the roles of genetics and gene expression as well as the influence of neurobiological mechanisms on stress and relapse risk. Future clinical implications of this research include identifying reliable indicators of relapse risk and the potential of pharmacotherapeutic treatments to target stress response systems to correct dysregulation and potentially reduce stress-related risk of relapse.

Evaluating Point of Sale Tobacco Marketing Using Behavioral Laboratory Methods

With passage of the 2009 Family Smoking Prevention and Tobacco Control Act, the FDA has authority to regulate tobacco advertising. As bans on traditional advertising venues and promotion of tobacco products have grown, a greater emphasis has been placed on brand exposure and price promotion in displays of products at the point-of-sale (POS). POS marketing seeks to influence attitudes and behavior towards tobacco products using a variety of explicit and implicit messaging approaches. Behavioral laboratory methods have the potential to provide the FDA with a strong scientific base for regulatory actions and a model for testing future manipulations of POS advertisements. We review aspects of POS marketing that potentially influence smoking behavior, including branding, price promotions, health claims, the marketing of emerging tobacco products, and tobacco counter-advertising. We conceptualize how POS marketing potentially influence individual attention, memory, implicit attitudes, and smoking behavior. Finally, we describe specific behavioral laboratory methods that can be adapted to measure the impact of POS marketing on these domains.

Behavioral Medicine in Primary Prevention

This article is a selective overview of behavioral medicine approaches to primary prevention. The main areas of discussion concern addictive behaviors and dietary factors. Overall, traditional educational approaches appear to succeed in altering understanding of these problems, but are less effective in actual prevention. More recently, behavioral medicine efforts, which focus on psychological and social influences, have demonstrated encouraging results. However, further systematic research is needed on these promising approaches before definitive conclusions can be drawn. Suggestions are provided for future primary prevention efforts as well as discernment of important mediating variables.

A summary of the recommendations for smoking cessation interventions: the quality assurance in the treatment of drug dependence project

This report presents outlines for approaches to smoking cessation. These recommendations are based on a meta-analysis of the treatment-outcome literature, a survey of current treatment practices and the views of a panel of experts. Face-to-face intervention to assist smokers to stop smoking needs to be considered in the context of a public policy approach to reducing the prevalence of smoking. The nature of face-to-face interventions is determined by the time available to practitioners. Where there is no time to intervene (e.g. in some primary health care settings) quality self-help materials should be prominently displayed. Where there is only 10 minutes or less, attention should be focused on personalizing the health effects of smoking, providing firm advice to quit, providing self-help material, setting a quit date (if appropriate), identifying social support for cessation and organizing a follow-up visit. If there is more time to intervene (up to one hour) the previous techniques can be expanded on and supplemented with nicotine replacement and discussion of methods for dealing with high-risk situations. Longer interventions would use all of these methods, presenting them in more detail, and may also address stress management and minimization of weight gain.

Alternative smoking cessation aids: a meta-analysis of randomized controlled trials

BACKGROUND

Acupuncture, hypnotherapy, and aversive smoking are the most frequently studied alternative smoking cessation aids. These aids are often used as alternatives to pharmacotherapies for smoking cessation; however, their efficacy is unclear.

METHODS

We carried out a random effect meta-analysis of randomized controlled trials to determine the efficacy of alternative smoking cessation aids. We systematically searched the Cochrane Library, EMBASE, Medline, and PsycINFO databases through December 2010. We only included trials that reported cessation outcomes as point prevalence or continuous abstinence at 6 or 12 months.

RESULTS

Fourteen trials were identified; 6 investigated acupuncture (823 patients); 4 investigated hypnotherapy (273 patients); and 4 investigated aversive smoking (99 patients). The estimated mean treatment effects were acupuncture (odds ratio [OR], 3.53; 95% confidence interval [CI], 1.03-12.07), hypnotherapy (OR, 4.55; 95% CI, 0.98-21.01), and aversive smoking (OR, 4.26; 95% CI, 1.26-14.38).

CONCLUSION

Our results suggest that acupuncture and hypnotherapy may help smokers quit. Aversive smoking also may help smokers quit; however, there are no recent trials investigating this intervention. More evidence is needed to determine whether alternative interventions are as efficacious as pharmacotherapies.

Relapse to smoking

Relapse is by far the most likely outcome of any smoking cessation attempt, even those made with the benefit intensive psychosocial treatment and pharmacotherapy. The present article briefly reviews the epidemiology of smoking and self-quitting, the outcome data for major forms of behavioral and pharmacologic smoking cessation treatments, and what is known about the natural history of relapse and recovery among treated smokers. A recent trend in smoking relapse research has been to study the dynamics of key motivational processes, such as withdrawal symptoms, negative affect, and craving, in the laboratory and in smokers' natural environments. This literature is also briefly reviewed, with an emphasis on how such investigations may reveal the limitations of current cessation treatments. Finally, three significant research themes that are likely to be important in future relapse research are highlighted--the possible "hardening" of the smoking population, the potential for developmental research to deepen our understanding of smoking motivation, and the promise of molecular genetic studies for advancing treatment and our understanding of relapse.

Aversive smoking for smoking cessation

BACKGROUND

Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke.

OBJECTIVES

This review has two aims: First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers to stop smoking; Second, to determine whether there is a dose-response effect on smoking cessation at different levels of aversive stimulation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for studies which evaluated any technique of aversive smoking.

SELECTION CRITERIA

Randomized trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow up of least six months from beginning of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomization and completeness of follow up. The outcome measure was abstinence from smoking at maximum follow up, using the strictest measure reported by the authors. Subjects lost to follow up were regarded as smokers. Where appropriate, we performed meta-analysis using a fixed effect model.

MAIN RESULTS

Twenty-five trials met the inclusion criteria. Twelve included rapid smoking and nine used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose-response to aversive stimulation. The odds ratio (OR) for abstinence following rapid smoking compared to control was 1.98 (95% confidence intervals (CI): 1.36 to 2.90). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non-significant result. Other aversion methods were not shown to be effective (odds ratio 1.15, 95% confidence interval 0.73 to 1.82). There was a borderline dose-response to the level of aversive stimulation (OR 1.66, 95% CI: 1.00 to 2.78).

REVIEWERS' CONCLUSIONS

The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose-response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology.

Aversive smoking for smoking cessation

BACKGROUND

Aversion therapy pairs the pleasurable stimulus of smoking a cigarette with some unpleasant stimulus. The objective is to extinguish the urge to smoke.

OBJECTIVES

This review has two aims. First, to determine the efficacy of rapid smoking and other aversive methods in helping smokers stop smoking. Second, to determine whether there is a dose-response effect on smoking cessation at different levels of aversive stimulation.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group trials register for studies which evaluated any technique of aversive smoking.

SELECTION CRITERIA

Randomised trials which compared aversion treatments with 'inactive' procedures or which compared aversion treatments of different intensity for smoking cessation. Trials must have reported follow-up of least 6 months from beginning of treatment.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the study population, the type of aversion treatment, the outcome measure, method of randomisation and completeness of follow-up. The outcome measure was abstinence from smoking at maximum follow-up, using the strictest measure reported by the authors. Subjects lost to follow-up were regarded as smokers. Where appropriate, we performed meta-analysis using a fixed effects model.

MAIN RESULTS

Twenty four trials met the inclusion criteria. Ten included rapid smoking and ten used other aversion methods. Ten trials included two or more conditions allowing assessment of a dose-response to aversive stimulation. The odds ratio for abstinence following rapid smoking compared to control was 2.08 (95% confidence interval 1.39 to 3.12). Several factors suggest that this finding should be interpreted cautiously. A funnel plot of included studies was asymmetric, due to the relative absence of small studies with negative results. Most trials had a number of serious methodological problems likely to lead to spurious positive results. The only trial using biochemical validation of all self reported cessation gave a non significant result. Other aversion methods were not shown to be effective (odds ratio 1.19, 95% confidence interval 0.77 to 1.83). There was a borderline dose-response to the level of aversive stimulation (odds ratio 1.66, 95% confidence interval 1.00 to 2.78).

REVIEWER'S CONCLUSIONS

The existing studies provide insufficient evidence to determine the efficacy of rapid smoking, or whether there is a dose-response to aversive stimulation. Milder versions of aversive smoking seem to lack specific efficacy. Rapid smoking is an unproven method with sufficient indications of promise to warrant evaluation using modern rigorous methodology.

Event-related brain potentials as indicators of smoking cue-reactivity

OBJECTIVE

Reactivity to smoking cues, shown previously by autonomic and self-report variables, was investigated in smokers and nonsmokers using event-related brain potentials (ERPs).

METHODS

Average ERPs to 20 color pictures of people smoking and 20 neutral pictures depicting nonsmoking themes, randomly mixed with 4 repetitions/stimulus, were measured from 20 light-moderate smokers and 18 nonsmokers, following a stressor. Smoker status and stimulus type effects on ERPs and principal components factor scores (FS) were tested by repeated-measures ANOVAs.

RESULTS

Smokers' N268 showed significant medial and midline smoking cue-reactivity (ERP to smoking-related minus neutral stimuli); while a P300-like, P412, showed significant smoking cue-reactivity over medial and left hemisphere scalp. FS analyses confirmed most of the foregoing. P412 smoking cue-reactivity was correlated with unpleasantness-pleasantness cue-reactivity but not with urge-to-smoke cue-reactivity. Nonsmokers' N268 stimulus differences were not significant, but significant P412 stimulus effects (unconfirmed by FS analyses) were found in central-to-posterior and in left parietal-temporal areas.

CONCLUSIONS

Smokers' N268 is identified with a process detecting stimuli incongruent with tobacco-addicted states; and P412 smoking cue-reactivity is discussed in terms of an automatic, perceptual-categorization system, consistent with Tiffany's drug-use and Johnson's P300 models. Implications of ERP smoking cue-reactivity for study of tobacco and other addictions are discussed.

Between knowledge and desire: perceptions of decision-making in the addictive behaviors

Behavioral change in the addictions is often conceptualized in terms of decision-making. It is argued that there are various problems and ambiguities inherent in the experimental research approach. An exploratory study across a range of dependencies (smoking, excessive gambling, drinking, and eating) is reported. The main aim is to examine personal accounts and views of the decision-making process instead of looking at this indirectly. Qualitative and quantitative evidence from a clinical and general population sample supports the perceived importance of decision-making across the dependencies studied. Such a process is thought to facilitate action and commitment. Firmness of decision in the clinical sample is significantly related to confidence in maintaining change. However, choices or decisions often involve relatively unsystematic processing. Blocks to implementation include unpleasant affect. The importance of understanding the link between affect and decision is emphasized as this is thought to be one of the critical determinants of successful change, yet is rarely explicitly studied. The discussion elaborates on possible ways of integrating decision-making with current clinical practice.

Assessment of the effects of urges and negative affect on smokers' coping skills

A taped-situation test designed to elicit descriptions of how subjects would cope with circumstances that placed them at high risk for relapse to smoking was administered to 60 cigarette smokers following their participation in one of three treatment groups. Two of these groups had coping-response training incorporated into the treatment format. The negative affect and urge contents of eight scenarios were manipulated to examine the effect of these variables on coping responses. The predictive validity of this assessment was evaluated by conducting follow-up interviews for up to 1 yr following the assessment. The manipulation of negative affect and urges had an impact on cognitive and behavioral coping. The type of treatment the subjects received had no effect on any of the coping-response measures. Among the 49 subjects abstinent at the time of the coping assessment, measures of coping (especially those obtained when urges and negative affect were increased) and self-efficacy ratings were predictive of days to first relapse. The implications of the results for the assessment of coping-responses and conceptualizations of the role of coping in the relapse process are discussed.

The production of smoking urges through an imagery manipulation: psychophysiological and verbal manifestations

This study examined physiological (heart rate, skin conductance, and finger temperature) responses and self-reported urges elicited by an imagery procedure designed to produce smoking urges. Sixty-six cigarette smokers were instructed to imagine vividly four audiotaped imagery scripts; two of the scripts contained explicit descriptions of smoking urge situations (urge scripts) while the other two were devoid of explicit urge content (neutral scripts). Physiological responses were monitored throughout each imagery trial and subjects rated the vividness of their image and intensity of their urge to smoke at the termination of each trial. Subjects reported significantly stronger urges to urge scripts than to neutral scripts. Urge scripts also produced increases in heart rate and higher tonic skin conductance levels than neutral scripts. These results suggest that the imagery procedure may have considerable potential in the study of the structure and function of drug urges. The theoretical implications of the data are discussed.

Postcessation cigarette use: the process of relapse

One hundred twenty-nine chronic smokers successfully completed a smoking cessation program composed of behavioral counseling and aversive smoking. During the two-year follow-up period, 92 of these subjects reported smoking. The progression from subjects' first cigarette to full relapse was examined via standardized telephone interviews. The latency between subjects' initial postcessation smoking episode and subsequent return to daily smoking was related to pretreatment confidence level, affective state at the time of the first cigarette, and origin of the first cigarette. Neither affective reaction nor coping response execution after the initial cigarette was related to the rate of relapse. Results are discussed in terms of current theory and treatment implications.

Smoking cessation and cardiovascular reactivity to stress

Systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) reactivity to mental arithmetic and deep knee bends were monitored in a sample of smokers prior to and 6 months following smoking cessation. There was no reduction in cardiovascular reactivity to either stressor following cessation. However, heightened pretreatment DBP and HR reactivity to mental arithmetic and SBP reactivity to deep knee bends were associated with relapse by the 6-month follow-up. Demographic and smoking history variables and pretreatment nicotine dependence were not associated with treatment outcome. Further exploration of cardiovascular reactivity to stress among smokers may elucidate the process of relapse.

Responses to smoking-related stimuli and early relapse to smoking

Prior to engaging in treatment for smoking cessation, subjects were tested for their responsiveness to cigarette smoking cues. Subjects performed a role-play with a confederate who lit their preferred brand of cigarette. Heart rate (HR) and galvanic skin conductance were assessed continuously, while urge to smoke and anxiety were rated subjectively after the role-play. Three months after treatment ended, subjects were divided into groups of continuous quitters, verified by expired carbon monoxide measurement, and relapsers. The results showed a significant difference between the groups in the pattern of pretreatment HR response to the lighting of the cigarette; relapsers displayed a sharp HR deceleration in response to the stimulus, while quitters' HR did not decelerate. The theoretical and clinical significance of these results is discussed.

A marijuana smoking cessation clinical trial utilizing THC-free marijuana, aversion therapy, and self-management counseling

Twenty-two volunteer adult chronic marijuana smokers participated in a smoking cessation clinical trial. The mean age of the 16 male and 6 female subjects was 29.8 years. The mean number of years of marijuana smoking was 13.7. The mean number of daily marijuana cigarettes smoked was 3.4. The clinical trial consisted of five consecutive days of 50 minute aversion therapy sessions (faradic, rapid smoking, and quick puffing) utilizing THC-free marijuana. Three weekly 60 minute group cohort sessions in self-management counseling followed. The treatment period spanned four weeks. Pretreatment and posttreatment (one month interval) the Shipley Institute of Living Scale was administered to measure changes in both cognitive functioning and organic brain dysfunction. All 22 subjects achieved abstinence (by self-report) by the end of the five days of aversion therapy; 19 of 21 subjects (90.5%) reported abstinence at the conclusion of the clinical trial, following the group sessions. At six months post treatment follow-up 15 of the 20 subjects (75.0%) reported abstinence; at 12 month posttreatment follow-up 16 of the 19 subjects (84.2%) achieved abstinence. The mean number of daily marijuana cigarettes smoked by the subjects decreased from a baseline pretreatment level of 3.40 to 0 at the conclusion of aversion therapy, .07 at the conclusion of the clinical trial, .26 at six month posttreatment follow-up and .23 at the 12 month posttreatment follow-up. The mean scores on the Shipley Institute of Living Scale, were: IQ 106 and CQ 92 at pretreatment; IQ 112 and CQ 104 at posttreatment. The difference in these means was significant for both intelligence and conceptual quotient. The investigators conclude that the treatment procedure offers promise as a marijuana smoking cessation treatment program.