Individual differences in the context of smoking lapse episodes

Nicotinic acetylcholine receptors in neurological and psychiatric diseases

Neuronal nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels that are widely distributed both pre- and post-synaptically in the mammalian brain. By modulating cation flux across cell membranes, neuronal nAChRs regulate neuronal excitability and the release of a variety of neurotransmitters to influence multiple physiologic and behavioral processes including synaptic plasticity, motor function, attention, learning and memory. Abnormalities of neuronal nAChRs have been implicated in the pathophysiology of neurologic disorders including Alzheimer's disease, Parkinson's disease, epilepsy, and Tourette´s syndrome, as well as psychiatric disorders including schizophrenia, depression, and anxiety. The potential role of nAChRs in a particular illness may be indicated by alterations in the expression of nAChRs in relevant brain regions, genetic variability in the genes encoding for nAChR subunit proteins, and/or clinical or preclinical observations where specific ligands showed a therapeutic effect. Over the past 25 years, extensive preclinical and some early clinical evidence suggested that ligands at nAChRs might have therapeutic potential for neurologic and psychiatric disorders. However, to date the only approved indications for nAChR ligands are smoking cessation and the treatment of dry eye disease. It has been argued that progress in nAChR drug discovery has been limited by translational gaps between the preclinical models and the human disease as well as unresolved questions regarding the pharmacological goal (i.e., agonism, antagonism or receptor desensitization) depending on the disease.

A Smartphone-Based Intervention for Anxiety and Depression in Racially and Ethnically Diverse Adults (EASE): Protocol for a Randomized Controlled Trial

BACKGROUND

Clear health disparities have emerged in the rates of COVID-19 exposure, hospitalization, and death among Black, Hispanic, and American Indian (BHAI) individuals, relative to non-Hispanic White (NHW) individuals. BHAI populations have been disproportionately affected by lower behavioral health access and heightened negative mental health outcomes during the pandemic.

OBJECTIVE

This project directly addresses health disparities in access to behavioral health care during the COVID-19 pandemic among BHAI populations via an adaptation of the established, initially validated, low-cost, mobile app Easing Anxiety Sensitivity for Everyone (EASE) among individuals with symptoms of elevated anxiety or depression or both.

METHODS

The EASE trial is a 2-arm, prospective, randomized, blinded-assessor study with intention-to-treat analysis. Participants (N=800; n=200, 25%, Black; n=200, 25%, Hispanic; n=200, 25%, American Indian; and n=200, 25%, NHW) are randomized to receive either EASE or an active comparison condition for anxiety and depression. Participants compete an online prescreener, an enrollment call to provide informed consent, a baseline survey, a 6-month intervention period, and 3- and 6-month postbaseline assessments. Select participants also complete a 3- and 6-month postbaseline qualitative interview via phone or an online platform (eg, Zoom). Participants complete 2 scheduled daily ecological momentary assessments (EMAs) during the 6-month study period. These twice-daily EMAs guide a just-in-time approach to immediate, personalized behavioral health care.

RESULTS

Outcomes include reductions in anxiety and depressive symptoms and functional impairment at 3 and 6 months postrandomization. We also will examine putative mechanisms (eg, anxiety sensitivity [AS] and COVID-19-specific stress and fear) of the intervention effects. Further, as treatment effects may differ across sociocultural factors, perceived discrimination, social support, and socioeconomic status (SES) will be evaluated as potential moderators of treatment effects on the primary outcomes. Process evaluation using data collected during the study, as well as individual interviews with participants, will complement quantitative data.

CONCLUSIONS

Data from this efficacy trial will determine whether EASE successfully improves symptoms of anxiety and depression and whether these improvements outperform an active comparison control app. If successful, findings from this study have the potential to decrease anxiety and depression symptoms among vulnerable populations determined to be most at risk of exacerbated, long-lasting negative health sequelae. Data from this study may be used to support an implementation and dissemination trial of EASE within real-world behavioral health and social service settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05074693; https://clinicaltrials.gov/ct2/show/NCT05074693.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40713.

An Integrated mHealth App for Smoking Cessation in Black Smokers With Anxiety: Protocol for a Randomized Controlled Trial

BACKGROUND

Black smokers have greater difficulty in quitting and higher rates of smoking-related diseases and disabilities than the general population. The smoking disparities experienced by this group are, in part, a consequence of multiple chronic life stressors (eg, racial discrimination) that engender increased exposure to interoceptive stress symptoms (eg, anxiety), which can ultimately lead to smoking as a means of immediate emotion regulation.

OBJECTIVE

This study aimed to culturally adapt and initially test a novel mobile intervention (ie, Mobile Anxiety Sensitivity Program for Smoking [MASP]) that targets anxiety sensitivity (AS; a proxy for difficulty and responsivity to interoceptive stress) among Black smokers. The MASP intervention is culturally informed to address interoceptive stress management difficulties among Black smokers and is thus hypothesized to facilitate smoking cessation.

METHODS

In phase 1, a total of 25 Black smokers with elevated AS will be administered MASP for 6 weeks. Following the completion of phase 1, we will further refine the MASP based on qualitative and quantitative data from participants to produce the final MASP iteration. In phase 2, a total of 200 Black smokers with elevated AS will be enrolled and randomly assigned to receive nicotine replacement therapy and either the smartphone-based National Cancer Institute QuitGuide app for standard mobile smoking cessation treatment or the MASP intervention. All participants in phases 1 and 2 will be enrolled remotely and will complete a web-based study screener; smartphone-based baseline assessment; daily smartphone-based ecological momentary assessments for 6 weeks; phone-based end-of-treatment qualitative interviews; and smartphone-based follow-up assessments at postbaseline weeks 1, 2 (quit date), 3, 4, 5, 6, 28, and 54 (weeks 28 and 54 follow-ups will be completed by phase 2 participants only). The MASP intervention is intended to offset barriers to treatment and encourage treatment engagement via smartphones.

RESULTS

This project was funded in September 2020. Phase 1 data collection began in January 2022. Phase 2 data collection is scheduled to begin in July 2022.

CONCLUSIONS

If successful, data from this study will support culturally informed treatment approaches for Black smokers and, pending findings of efficacy, provide an evidence-based mobile intervention for smoking cessation that is ready for dissemination and implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04838236; https://clinicaltrials.gov/ct2/show/NCT04838236.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38905.

Predicting Daily Sheltering Arrangements among Youth Experiencing Homelessness Using Diary Measurements Collected by Ecological Momentary Assessment

Youths experiencing homelessness (YEH) often cycle between various sheltering locations including spending nights on the streets, in shelters and with others. Few studies have explored the patterns of daily sheltering over time. A total of 66 participants completed 724 ecological momentary assessments that assessed daily sleeping arrangements. Analyses applied a hypothesis-generating machine learning algorithm (component-wise gradient boosting) to build interpretable models that would select only the best predictors of daily sheltering from a large set of 92 variables while accounting for the correlated nature of the data. Sheltering was examined as a three-category outcome comparing nights spent literally homeless, unstably housed or at a shelter. The final model retained 15 predictors. These predictors included (among others) specific stressors (e.g., not having a place to stay, parenting and hunger), discrimination (by a friend or nonspecified other; due to race or homelessness), being arrested and synthetic cannabinoids use (a.k.a., “kush”). The final model demonstrated success in classifying the categorical outcome. These results have implications for developing just-in-time adaptive interventions for improving the lives of YEH.

A randomized controlled trial protocol for engaging distress tolerance and working memory to aid smoking cessation in low socioeconomic status (SES) adults

Low income and low educational attainment are among the strongest predictors of both smoking prevalence and lapse (i.e., return) to smoking after cessation attempts. Treatment refinement is limited by inadequate knowledge of the specific lapse- or relapse-relevant vulnerabilities characteristic of populations that should be the target of treatment. In the context of a randomized clinical trial design, we describe an experimental medicine approach for evaluating the role of 2 specific lapse-relevant targets relative to the higher stress characteristic of low-socioeconomic contexts: low distress tolerance and low working memory capacity. Furthermore, we use an innovative approach for understanding risk of smoking lapse in smokers undergoing a quit attempt to examine candidate mechanistic targets assessed not only during nicotine use, but also during the conditions smokers will face upon a cessation attempt-during stressful nicotine-deprivation windows. This study is designed to show the incremental value of assessments during deprivation windows, in part because of the way in which specific vulnerabilities are modified by, and interact with, the heightened stress and withdrawal symptoms inherent to nicotine-deprivation states. Specifically, the study is designed to evaluate whether a novel mindfulness intervention (mindfulness combined with interoceptive exposure) can improve upon existing mindfulness interventions and extend therapeutic gains to the modification of mechanistic targets assessed in high-stress or negative affectivity contexts. The overall goal is to validate mechanistic targets and associated interventions for the purpose of expanding treatment options for at-risk smokers. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Isradipine enhancement of virtual reality cue exposure for smoking cessation: Rationale and study protocol for a double-blind randomized controlled trial

Cigarette smoking remains a leading cause of preventable death in the United States, contributing to over 480,000 deaths each year. Although significant strides have been made in the development of effective smoking cessation treatments, most established interventions are associated with high relapse rates. One avenue for increasing the effectiveness of smoking cessation interventions is to design focused, efficient, and rigorous experiments testing engagement of well-defined mechanistic targets. Toward this aim, the current protocol will apply a pharmacologic augmentation strategy informed by basic research in animal models of addiction. Our goal is to evaluate the enhancing effect of isradipine, an FDA-approved calcium channel blocker, on the extinction of craving-a key mechanism of drug relapse after periods of abstinence. To activate craving robustly in human participants, we will use multimodal smoking cues including novel 360° video environments developed for this project and delivered through consumer virtual reality headsets. Adult smokers will take either isradipine or placebo and complete the cue exposure protocol in a double-blind randomized control trial. In order to test the hypothesis that isradipine will enhance retention of craving extinction, participants will repeat cue exposure 24 h later without the administration of isradipine or placebo. The study will be implemented in a primary care setting where adult smokers receive healthcare, and smoking behavior will be tracked throughout the trial with ecological momentary assessment.

The time-varying effect of alcohol use on cigarette smoking relapse risk

BACKGROUND

Alcohol consumption promotes lapses to smoking among smokers trying to quit, perhaps particularly among smokers with lower dependence. We assessed how the role of alcohol in lapses varies over time.

METHODS

This is a secondary analysis of ecological momentary assessment data collected from 159 daily smokers (mean age = 43.90 (SD = 10.41), 56.60% female) who drink alcohol. During the 4 weeks following initial cessation (quit >24 h), a logistic time-varying effect model (TVEM) modeled momentary assessments of lapses and temptations to smoke compared to randomly-selected moments as a function of concurrently-assessed recent alcohol use (past 15 min). Time was examined continuously.

RESULTS

Recent alcohol use was associated with smoking lapses, particularly for less nicotine dependent individuals, and the association varied across time. For individuals who did not smoke within 5 min of waking, alcohol use became a significant predictor of lapse on Day 1 post-quit, increased in strength until Day 7, then decreased such that alcohol use was no longer associated with lapse by Day 25. For this subgroup, the associations between alcohol use and temptations were relatively stable and significant from Day 1 to 22 post-quit. Results were similar when dependence was assessed by the Nicotine Dependence Symptom Scale.

CONCLUSIONS

The association between drinking and smoking lapse and temptations varies over time, peaking early in smoking abstinence and declining thereafter. This could reflect progressive relapse of most vulnerable individuals or habituation to alcohol as a smoking cue. Interventions to prevent alcohol-related lapses are essential early in the quit period.

Enhancing panic and smoking reduction treatment with D-Cycloserine: A pilot randomized clinical trial

In this placebo-controlled randomized clinical trial, we examined the efficacy of 250 mg d-cycloserine (DCS) for enhancing the effects of cognitive behavior therapy targeting anxiety sensitivity reduction in the context of smoking cessation treatment among adults with a history of panic attacks. We hypothesized that DCS would enhance treatment of our mechanistic targets-anxiety sensitivity and panic and related symptoms-and result in greater smoking abstinence. A total of 53 smokers were randomized to a 7-week integrated treatment and received study medication (DCS or placebo) prior to sessions 3-5; these sessions emphasized interoceptive exposure practice. Nicotine replacement therapy was initiated at session 5 (quit date). We found that DCS augmentation led to greater reductions of one (anxiety sensitivity) of two of our mechanistic targets at early but not late assessments, and that engaging that target predicted better smoking outcomes. However, there was no evidence of group (DCS vs. placebo) differences in smoking cessation success at treatment endpoint or follow-up evaluations. Hence, although we found that DCS can enhance treatment targeting a smoking maintaining factor, additional strategies appear to be needed to significantly affect smoking outcomes.

Effect of nicotine 6 mg gum on urges to smoke, a randomized clinical trial

BACKGROUND

Ability to manage urges to smoke is fundamental to maximizing the chances of success in smoking cessation. Previous studies have linked a higher dose of nicotine in nicotine replacement therapy to a higher success rate for smoking cessation. Thus, this study was performed to compare relief of urges to smoke, up until 5 h following treatment with a new 6 mg nicotine gum versus currently marketed 4 mg nicotine gum.

METHODS

This was a randomized crossover clinical study. Following 12 h of abstinence from smoking, either one 6 mg or one 4 mg nicotine gum was given to 240 healthy adult smokers. Thereafter, urges to smoke were scored on a 100 mm Visual Analogue Scale repeatedly over 5 h.

RESULTS

The reductions in urges to smoke over the first 1 and 3 h after administration were statistically significantly greater with 6 mg than 4 mg gum, (p < 0.005). A 50% reduction in perceived urges to smoke was reached in 9.4 min with 6 mg gum compared to 16.2 min with 4 mg gum (median values). The median duration of a 50% or more reduction in VAS urges to smoke score was 111 min with the 6 mg gum, versus 74 min for the 4 mg gum.

CONCLUSION

This study provides evidence that the 6 mg nicotine gum provided a greater reduction, faster and longer relief of urges to smoke than the 4 mg nicotine gum.

TRIAL REGISTRATION

EudraCT Number: 2010-023268-42. Study was first entered in EudraCT 2011-02-23.

Momentary precipitants connecting stress and smoking lapse during a quit attempt

OBJECTIVE

Most attempts at smoking cessation are unsuccessful, and stress is frequently characterized both as a momentary precipitant of smoking lapse and a predictor of subsequent changes in other key precipitants of lapse. The current study examined longitudinal associations among stress, multiple precipitants of lapse, and lapse among smokers attempting to quit.

METHOD

Ecological momentary assessments (EMAs) were gathered from a multiethnic, gender-balanced sample of 370 adults enrolled in a smoking cessation program. EMAs (N = 32,563) assessed smoking lapse and precipitants of lapse, including stress, negative affect, smoking urge, abstinence self-efficacy, motivation to quit, difficulty concentrating, coping outcome expectancies, and smoking outcome expectancies. A multilevel structural equation model simultaneously estimated within-subject paths from stress to multiple precipitants and subsequent smoking lapse. Indirect effects of stress to smoking lapse through precipitants were computed.

RESULTS

Results indicated that increased stress was significantly associated with all precipitants of lapse, consistent with a greater risk for lapse (i.e., increased negative affect, smoking urge, difficulty concentrating, and smoking outcome expectancies and reduced abstinence self-efficacy, motivation to quit, and coping outcome expectancies). All precipitants were significantly associated with subsequent lapse. Indirect effects indicated that stress was uniquely connected to lapse through negative affect, smoking urge, abstinence self-efficacy, coping outcome expectancies, and smoking outcome expectancies.

CONCLUSIONS

Results of this study highlight the broad importance of stress for smoking lapse during a quit attempt. Smoking cessation programs should pay close attention to the role of stress in exacerbating key precipitants of lapse to improve cessation success rates. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Financial strain mediates the relationship between socioeconomic status and smoking

INTRODUCTION

Smoking is the leading cause of preventable death accounting for about 0.48 million deaths in the US every year. Across the socioeconomic status (SES) gradient smoking prevalence differs greatly, with those of lower SES smoking at much higher rates than those of higher SES. Previous studies have shown relationships between socioeconomic status, financial strain, and smoking. However, little research has explored the possibility that financial strain might mediate the relationship between socioeconomic status and smoking. Thus, the goal of the current study was to determine whether financial strain was a mediating factor in the relationship between socioeconomic status and smoking.

METHODS

Participants (N=238) were primarily female (67.6%) and African-American adults (51.7%) from the Dallas metropolitan area. The majority of the sample reported that they did not currently smoke (n=164). Participants who reported currently smoking at baseline (n=74) smoked an average of 9.96 (SD=10.79) cigarettes per day.

RESULTS

Analyses revealed that financial strain partially mediates the relationship between socioeconomic status and smoking status. Additionally, financial strain was found to significantly partially mediate the relationship between socioeconomic status and cigarettes smoked prospectively over the next 7 days.

CONCLUSIONS

Overall, findings suggest that greater financial strain may be one factor that links SES with current smoking and smoking level among those who smoke.

Using mHealth to Increase Treatment Utilization Among Recently Incarcerated Homeless Adults (Link2Care): Protocol for a Randomized Controlled Trial

Background

There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive professional coordination of individualized care (ie, case management) during the period following their release from jail experience fewer mental health and substance use problems, are more likely to obtain stable housing, and are less likely to be reincarcerated. This is because case managers work to meet the various needs of their clients by helping them to overcome barriers to needed services (eg, food, clothing, housing, job training, substance abuse and mental health treatment, medical care, medication, social support, proof of identification, and legal aid). Many barriers (eg, limited transportation, inability to schedule appointments, and limited knowledge of available services) prevent homeless adults who were recently released from incarceration from obtaining available case management, crisis management, substance abuse, and mental health services.

Objective

The aim of the Link2Care study is to assess the effectiveness of a smartphone app for increasing case management and treatment service utilization, and in turn reduce homelessness and rearrest. The goals of this research are to (1) assess the impact of an innovative smartphone app that will prompt and directly link recently incarcerated homeless adults to community-based case management services and resources and (2) utilize in-person and smartphone-based assessments to identify key variables (eg, alcohol or drug use, social support, psychological distress, and quality of life) that predict continued homelessness and rearrest.

Methods

Homeless adults (N=432) who enroll in a shelter-based Homeless Recovery Program after release from the Dallas County Jail will be randomly assigned to one of the three treatment groups: (1) usual case management, (2) usual case management plus smartphone, and (3) usual case management with a study-provided smartphone that is preloaded with an innovative case management app (smartphone-based case management). Those assigned to smartphone-based case management will receive smartphones that prompt (twice weekly) connections to shelter-based case managers. The app will also offer direct links to case managers (available during normal business hours) and crisis interventionists (available 24 hours a day, 7 days a week) with the touch of a button.

Results

Recruitment began in the spring of 2018, and data collection will conclude in 2021.

Conclusions

This research represents an important step toward integrated service connection and health care service provision for one of the most underserved, high need, and understudied populations in the United States.

Trial Registration

ClinicalTrials.gov NCT03399500; https://clinicaltrials.gov/ct2/show/NCT03399500 (Archived by WebCite at http://www.webcitation.org/6zSJwdgUS)

Registered Report Identifier

RR1-10.2196/9868

Predicting Sexual Behaviors Among Homeless Young Adults: Ecological Momentary Assessment Study

BACKGROUND

Homeless youth continue to be disproportionately affected by HIV compared with their housed peers, with prevalence rates as high as 13%. Yet, HIV prevention in this high-risk population has been only marginally effective.

OBJECTIVE

The aim of this study was to use ecological momentary assessments to examine real-time factors to determine the predictors of sexual activity among homeless youth.

METHODS

Youth experiencing homelessness aged between 18 and 24 years were recruited from a drop-in center in Houston, Texas, between August 2015 and May 2016. All the participants received a study-issued mobile phone that prompted brief ecological momentary assessments (EMAs) 5 times a day for 21 days. EMA items assessed near real-time sexual behaviors, cognitions, stress, affect, environmental factors, and environmental circumstances.

RESULTS

Participants (N=66) were predominantly male (41/66, 64%) and black (43/66, 66%) with a median age of 20 years. The mean number of EMAs completed by each participant was 45 out of 105 possible observations. During the study, 70% (46/66) of participants were sexually active and reported condomless sex in 102 of the 137 cases of sexual intercourse (74.5%). In total, 82% (38/46) of the youth who reported having sex during the 3 weeks of data collection also reported engaging in high-risk sexual activities, including having condomless sex (24/46, 53%), having multiple sexual partners on the same day (12/46, 26%), trading sex (7/46, 16%), and sharing needles while injecting drugs (1/46, 3%). Of those, 71% (27/38) were engaged in multiple sexual risk behaviors. The predictive model was based on observations from 66 subjects who reported 137 cases of sexual intercourse over 811 days; sexual orientation, race, mental health, drug use, and sexual urge were included as predictors in the parsimonious generalized linear mixed model selected on the basis of the Akaike information criterion. The estimated odds ratios (ORs) were notable for same-day drug use (OR 2.17, 95% CI 4.48-17.31; P<.001) and sexual urge (OR 1.44, 95% CI 1.60-11.28; P=.004). The performance of the risk estimator was satisfactory, as indicated by the value of 0.834 for the area under the receiver operating characteristic curve.

CONCLUSIONS

Real-time EMA data can be used to predict sexual intercourse among a sample of high-risk, predominately unsheltered homeless youth. Sexual urge and drug use accounts for increased odds of engaging in sexual activity on any given day. Interventions targeting sexual urge and drug use may help predict sexual activity among a population at high risk of HIV.

Drug use patterns and predictors among homeless youth: Results of an ecological momentary assessment

BACKGROUND

Alcohol and drug use is associated with significant morbidity and mortality and is highly prevalent among homeless youth. Ecological Momentary Assessments (EMA) have been used to examine the effect of urges on drug use, though not among homeless youth.

OBJECTIVES

We assessed the patterns of drug use and the correlation between real-time contextual factors and drug use using EMA collected daily. We identified predictors of drug use among a sample of homeless youth 18-25 years old in Houston, Texas.

METHODS

Homeless youth (n = 66, 62% male) were recruited from a drop-in center between September 2015 and May 2016. We used generalized linear mixed models and cross-validation methods to determine the best predictive model of drug use.

RESULTS

The overall drug use was high: 61% and 32% of participants reported using drugs or alcohol at least one day, respectively. Marijuana and synthetic marijuana use (i.e., Kush, K2, incense packs) were reported most frequently; 86% and 13% of the total drug use EMAs, respectfully. Drug use urge was reported on 26% of days and was the highest on drug use days. Drug use was predicted by discrimination, pornography use, alcohol use, and urges for drugs, alcohol, and to steal.

CONCLUSIONS

EMA can be used to predict drug use among homeless youth. Drug use treatment among homeless youth should address the role of experiencing discrimination, pornography and alcohol use, and urge management strategies on drug use. Research is needed to determine if EMA informed just-in-time interventions targeting these predictors can reduce use.

The social networks of smokers attempting to quit: An empirically derived and validated classification

Social relationships play an important role in the uptake, maintenance, and cessation of smoking behavior. However, little is known about the natural co-occurrence of social network features in adult smokers' networks and how multidimensional features of the network may connect to abstinence outcomes. The current investigation examined whether qualitatively distinct subgroups defined by multiple characteristics of the social network could be empirically identified within a sample of smokers initiating a quit attempt. Egocentric social network data were collected from 1571 smokers (58% female, 83% white) engaged in a 3-year smoking cessation clinical trial. Using nine indicator variables reflecting both risk and protective network features, finite mixture models identified five social network subgroups: High Stress/High Contact, Large and Supportive, Socially Disconnected, Risky Friends and Low Contact, and High Contact with Smokers and Light Drinkers. External variables supported the validity of the identified subgroups and the subgroups were meaningfully associated with baseline demographic, psychiatric, and tobacco measures. The Socially Disconnected subgroup was characterized by little social interaction, low levels of stress, and low exposure to social environmental smoking cues, and had the highest probability of successful cessation at 1 week compared with all other social network subgroups. At 6 months posttreatment its members had higher abstinence rates than members of the High Stress/High Contact subgroup and the Risky Friends and Low Contact subgroup. The present study highlights the heterogeneity of smokers' social milieus and suggests that network features, especially those entailing exposure to smoking cues and contexts, heighten risk for smoking cessation failure. (PsycINFO Database Record

Reduction of smoking urges with intranasal insulin: a randomized, crossover, placebo-controlled clinical trial

Many cigarette smokers express a desire to quit smoking, but ~85% of cessation attempts fail. In our attempt to delineate genetic modulators of smoking persistence, we have earlier shown that a locus within an ~250 kb haplotype block spanning the 5' untranslated region region of insulin-degrading enzyme is associated with serum cotinine levels; the study's measure of smoking quantity. Based on our findings, and coupled with recent preclinical studies showing the importance of multiple neuropeptides in reinstatement of drug use, we formulated intranasal insulin to evaluate its efficacy during acute abstinence from smoking. Our original study was a crossover trial including 19 otherwise healthy smokers who abstained from smoking for 36 h. The morning following their second night of abstinence, in random order, study participants received intranasal insulin (60 IU) or placebo (8.7% sodium chloride). The goal of our second study was to replicate the craving findings from the original trial and expand this research by including additional stress-related measures. Thirty-seven study participants abstained from smoking overnight. The next day, they were administered either intranasal insulin (60 IU) or placebo, following which they participated in the Trier Social Stress Test Task. This was a parallel design study focusing on the standard stress subjective, hormonal and cardiovascular measures. We also evaluated any changes in circulating glucose, insulin and c-peptide (a marker of endogenous insulin). In the original study, intranasal insulin significantly reduced morning nicotine craving (b=3.65, P⩽0.05). Similarly, in the second study, intranasal insulin reduced nicotine cravings over time (b=0.065, P⩽0.05) and the effect lasted through the psychosocial stress period. Intranasal insulin also increased circulating cortisol levels (F=12.78, P⩽0.001). No changes in insulin or c-peptide were detected. A significant treatment × time interaction (P⩽0.05) was detected for glucose, but subjects remained well within the euglycemic range. Previous studies have shown that heightened nicotine cravings and blunted response to stress are independent and significant predictors of relapse to smoking. In our study, intranasal insulin normalized the subjective and hormonal response to stress. As such, intranasal insulin should further be studied in a larger clinical trial of smoking cessation. In support of this, we provide evidence that the treatment is safe and effective and, based on absence of peripheral insulin changes, conclude that the pharmacodynamic effect is centrally driven.

Evaluating the influence of at-risk alcohol use on factors associated with smoking cessation: Combining laboratory and ecological momentary assessment

OBJECTIVE

Most smokers want to quit but most cessation attempts end in failure. Alcohol consumption is associated with smoking behavior and relapse. We examined the associations between severity of drinking and psychological processes during a cessation attempt in the laboratory and during a quit attempt.

METHODS

Smokers (N=209) enrolled in a smoking cessation study were followed from 2 weeks pre-quit through 4 weeks post-quit. Participants scoring 0-7 and 8-15 on the Alcohol Use Disorders Identification Test (AUDIT) were classified as low-risk and high-risk drinkers, respectively. Participants attended one pre-quit laboratory session before which they were required to abstain from smoking and another pre-quit session before which they smoked normally. Craving was assessed in the laboratory with the Questionnaire for Smoking Urges (QSU). A subsample of the participants also completed a 1-week ecological momentary assessment (EMA) study starting on the quit day. During EMA, craving for cigarettes was assessed, and attentional bias was assessed using a smoking Stroop task (n=119).

RESULTS

High (vs. low) risk participants reported greater abstinence-induced increases in craving in the laboratory, and also exhibited greater attentional bias on the smoking Stroop task during EMA.

CONCLUSIONS

High-risk drinkers exhibited a stronger increase in desire to smoke in abstinence and greater attentional bias to smoking cues early in a quit attempt, both of which may motivate continued smoking behaviors. High-risk drinkers may require more intensive or different smoking cessation interventions.

An Ecological Momentary Intervention for Smoking Cessation: Evaluation of Feasibility and Effectiveness

BACKGROUND

Despite substantial public health progress in reducing the prevalence of smoking in the United States overall, smoking among socioeconomically disadvantaged adults remains high.

OBJECTIVE

To determine the feasibility and preliminary effectiveness of a novel smartphone-based smoking cessation app designed for socioeconomically disadvantaged smokers.

METHODS

Participants were recruited from a safety-net hospital smoking cessation clinic in Dallas, Texas, and were followed for 13 weeks. All participants received standard smoking cessation clinic care (ie, group counseling and cessation pharmacotherapy) and a smartphone with a novel smoking cessation app (ie, Smart-T). The Smart-T app prompted 5 daily ecological momentary assessments (EMAs) for 3 weeks (ie, 1 week before cessation and 2 weeks after cessation). During the precessation period, EMAs were followed by messages that focused on planning and preparing for the quit attempt. During the postcessation period, participant responses to EMAs drove an algorithm that tailored messages to the current level of smoking lapse risk and currently present lapse triggers (eg, urge to smoke, stress). Smart-T offered additional intervention features on demand (eg, one-click access to the tobacco cessation quitline; "Quit Tips" on coping with urges to smoke, mood, and stress).

RESULTS

Participants (N=59) were 52.0 (SD 7.0) years old, 54% (32/59) female, and 53% (31/59) African American, and 70% (40/57) had annual household income less than US $16,000. Participants smoked 20.3 (SD 11.6) cigarettes per day and had been smoking for 31.6 (SD 10.9) years. Twelve weeks after the scheduled quit date, 20% (12/59) of all participants were biochemically confirmed abstinent. Participants responded to 87% of all prompted EMAs and received approximately 102 treatment messages over the 3-week EMA period. Most participants (83%, 49/59) used the on-demand app features. Individuals with greater nicotine dependence and minority race used the Quit Tips feature more than their counterparts. Greater use of the Quit Tips feature was linked to nonabstinence at the 2 (P=.02), 4 (P<.01), and 12 (P=.03) week follow-up visits. Most participants reported that they actually used or implemented the tailored app-generated messages and suggestions (83%, 49/59); the app-generated messages were helpful (97%, 57/59); they would like to use the app in the future if they were to lapse (97%, 57/59); and they would like to refer friends who smoke to use the Smart-T app (85%, 50/59). A minority of participants (15%, 9/59) reported that the number of daily assessments (ie, 5) was "too high."

CONCLUSIONS

This novel just-in-time adaptive intervention delivered an intensive intervention (ie, 102 messages over a 3-week period), was well-liked, and was perceived as helpful and useful by socioeconomically disadvantaged adults who were seeking smoking cessation treatment. Smartphone apps may be used to increase treatment exposure and may ultimately reduce tobacco-related health disparities among socioeconomically disadvantaged adults.

Hazardous Alcohol Drinking as Predictor of Smoking Relapse (3-, 6-, and 12-Months Follow-Up) by Gender

Diverse studies have found a relation between alcohol consumption and smoking relapse. Few studies have analyzed the relation of smoking relapse with pretreatment alcohol consumption and gender differences. The main purpose of this study is to analyze the influence of alcohol consumption in smoking relapse over 12 months (3-, 6-, and 12-months follow-up) and to determine possible gender differences. The sample included 374 smokers who quit smoking by participating in a psychological smoking cessation treatment. We assessed hazardous pretreatment alcohol drinking (AUDIT), cigarette consumption (FTND; number of cigarettes) and sociodemographic variables. Higher scores on hazardous pretreatment alcohol drinking predict smoking relapse at 3-, 6-, and 12-months after smoking cessation. In males, higher scores on hazardous pretreatment alcohol drinking predict relapse at 6 and at 12 months. In females, higher scores on hazardous pretreatment alcohol drinking predict tobacco relapse at 3 months. Hazardous pretreatment alcohol drinking predicts relapse at all intervals after smoking cessation (3-, 6-, and 12-months follow-up). However, the influence of hazardous pretreatment alcohol drinking on smoking relapse differs as a function of gender, as it is a short-term predictor in women (3 months) and a long-term predictor in men (6 and 12 months).

Triggers of Smoking Lapses Over the Course of a Quit Attempt

Introduction: Both withdrawal severity and smoking cues can trigger lapses. However, the temporal relationship between these two sets of triggers is unknown.

Aims: To explore the time course of lapse triggers during a quit attempt.

Methods: Across two cessation studies, 186 lapsers monitored their smoking in real-time for up to 7 weeks over the course of a quit attempt. During lapses, participants were asked to report the primary trigger of the event; this, including the time of the event relative to quit day, was logged by an electronic diary. Log multinomial regression was used to estimate the probability that each lapse would be withdrawal-triggered or cue-triggered.

Results: Log multinomial regression showed that the probability of a first lapse being triggered by withdrawal rose in the initial days of a quit attempt before dropping as the quit attempt progressed (P < 0.01). The probability of a cue-triggered lapse rose over the course of a quit attempt (P < 0.05).

Conclusions: The results are consistent both with the time course of withdrawal symptoms and with theoretical predictions about the relationship between nicotine dependence and stimulus control. The results have implications for tailoring smoking-cessation treatments; in particular, for the stepwise provision of smoking-cessation assistance over the course of a quit attempt.

Acute administration of nicotine into the higher order auditory Te2 cortex specifically decreases the fear-related charge of remote emotional memories

Nicotine elicits several behavioural effects on mood as well as on stress and anxiety processes. Recently, it was found that the higher order components of the sensory cortex, such as the secondary auditory cortex Te2, are essential for the long-term storage of remote fear memories. Therefore, in the present study, we examined the effects of acute nicotine injection into the higher order auditory cortex Te2, on the remote emotional memories of either threat or incentive experiences in rats. We found that intra-Te2 nicotine injection decreased the fear-evoked responses to a tone previously paired with footshock. This effect was cue- and dose-specific and was not due to any interference with auditory stimuli processing, innate anxiety and fear processes, or with motor responses. Nicotine acts acutely in the presence of threat stimuli but it did not determine the permanent degradation of the fear-memory trace, since memories tested one week after nicotine injection were unaffected. Remarkably, nicotine did not affect the memory of a similar tone that was paired to incentive stimuli. We conclude from our results that nicotine, when acting acutely in the auditory cortex, relieves the fear charge embedded by learned stimuli.

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Nicotine reliefs fear memories.

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Nicotine acts on long-term memories.

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Nicotine modulates memory in auditory cortex.

Predicting use of assistance when quitting: a longitudinal study of the role of quitting beliefs

BACKGROUND

A growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments.

PURPOSE

To examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit.

METHODS

The present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting.

RESULTS

The hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance.

CONCLUSIONS

The present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

Anxiolytic-like and anxiogenic-like effects of nicotine are regulated via diverse action at β2*nicotinic acetylcholine receptors

BACKGROUND AND PURPOSE

Nicotine dose-dependently activates or preferentially desensitizes β2 subunit containing nicotinic ACh receptors (β2*nAChRs). Genetic and pharmacological manipulations assessed effects of stimulation versus inhibition of β2*nAChRs on nicotine-associated anxiety-like phenotype.

EXPERIMENTAL APPROACH

Using a range of doses of nicotine in β2*nAChR subunit null mutant mice (β2KO; backcrossed to C57BL/6J) and their wild-type (WT) littermates, administration of the selective β2*nAChR agonist, 5I-A85380, and the selective β2*nAChR antagonist dihydro-β-erythroidine (DHβE), we determined the behavioural effects of stimulation and inhibition of β2*nAChRs in the light-dark and elevated plus maze (EPM) assays.

KEY RESULTS

Low-dose i.p. nicotine (0.05 mg·kg(-) 1) supported anxiolysis-like behaviour independent of genotype whereas the highest dose (0.5 mg·kg(-1) ) promoted anxiogenic-like phenotype in WT mice, but was blunted in β2KO mice for the measure of latency. Administration of 5I-A85380 had similar dose-dependent effects in C57BL/6J WT mice; 0.001 mg·kg(-1) 5I-A85380 reduced anxiety on an EPM, whereas 0.032 mg·kg(-1) 5I-A85380 promoted anxiogenic-like behaviour in both the light-dark and EPM assays. DHβE pretreatment blocked anxiogenic-like effects of 0.5 mg·kg(-1) nicotine. Similarly to DHβE, pretreatment with low-dose 0.05 mg·kg(-1) nicotine did not accumulate with 0.5 mg·kg(-1) nicotine, but rather blocked anxiogenic-like effects of high-dose nicotine in the light-dark and EPM assays.

CONCLUSIONS AND IMPLICATIONS

These studies provide direct evidence that low-dose nicotine inhibits nAChRs and demonstrate that inhibition or stimulation of β2*nAChRs supports the corresponding anxiolytic-like or anxiogenic-like effects of nicotine. Inhibition of β2*nAChRs may relieve anxiety in smokers and non-smokers alike.

Ecological momentary assessment in the investigation of craving and substance use in daily life: a systematic review

BACKGROUND

Craving is viewed as a major determinant of relapse in persons with substance addiction, but this association remains poorly understood due to its time-limited nature and the biases associated with retrospective reporting. Ecological momentary assessment (EMA) offers new opportunities to examine both craving and substance use with strong ecological validity by collecting real-time data in daily life. This review examined all published studies using EMA to: (1) assess the link between craving and substance use; and (2) identify relevant moderators of craving among substance users.

METHODS

We searched PubMed and PsycInfo databases up to October 31, 2013.

RESULTS

Ninety-one studies were selected, involving mostly tobacco smokers (73%). A majority of studies (92%) reported a positive relationship between craving and substance use, concurrently and prospectively, and among users with different levels of use for both legal and illegal substances. Results suggest that craving is a stronger predictor of relapse episodes when assessed in close temporal proximity to substance use. EMA data also confirmed the influence of diverse within-person and between-person sources of variation in daily life craving reports.

CONCLUSIONS

This review provides strong support for the link between craving and substance use, and underscores the importance of the timing of assessments.

Effects of marijuana use on impulsivity and hostility in daily life

BACKGROUND

Marijuana use is increasingly prevalent among young adults. While research has found adverse effects associated with marijuana use within experimentally controlled laboratory settings, it is unclear how recreational marijuana use affects day-to-day experiences in users. The present study sought to examine the effects of marijuana use on within-person changes in impulsivity and interpersonal hostility in daily life using smartphone administered assessments.

METHODS

Forty-three participants with no substance dependence reported on their alcohol consumption, tobacco use, recreational marijuana use, impulsivity, and interpersonal hostility over the course of 14 days. Responses were analyzed using multilevel modeling.

RESULTS

Marijuana use was associated with increased impulsivity on the same day and the following day relative to days when marijuana was not used, independent of alcohol use. Marijuana was also associated with increased hostile behaviors and perceptions of hostility in others on the same day when compared to days when marijuana was not used. These effects were independent of frequency of marijuana use or alcohol use. There were no significant effects of alcohol consumption on impulsivity or interpersonal hostility.

CONCLUSIONS

Marijuana use is associated with changes in impulse control and hostility in daily life. This may be one route by which deleterious effects of marijuana are observed for mental health and psychosocial functioning. Given the increasing prevalence of recreational marijuana use and the potential legalization in some states, further research on the potential consequences of marijuana use in young adults' day-to-day life is warranted.

Preliminary effects of progressive muscle relaxation on cigarette craving and withdrawal symptoms in experienced smokers in acute cigarette abstinence: a randomized controlled trial

BACKGROUND

Cigarette craving usually occurs in conjunction with unpleasant feelings, including stress, as part of a withdrawal syndrome. Progressive muscle relaxation (PMR), a behavioral technique used to reduce stress by concentrating on achieving muscle relaxation, may reduce levels of cigarette craving and other substance-related negative feelings and withdrawal symptoms.

METHODS

Demographic and cigarette use data were collected from 32 experienced smokers at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand using the Semi-Structured Assessment for Drug Dependence and Alcoholism. Participants were asked to refrain from smoking for at least 3 hours before the visit (acute abstinence) and were randomly allocated to a 1-session PMR group (n =16) or a control activity group (e.g., reading newspaper, n =16). The intervention group was instructed to practice PMR individually in a quiet, private, air-conditioned room for about 20minutes. Craving, other substance-related feelings, and autonomic nervous responses (e.g., blood pressure and pulse rate) were assessed immediately before and after the 1-session intervention.

RESULTS

There were no differences in demographics, cigarette use/dependence, and baseline craving characteristics between the PMR and control groups. However, the control group had higher levels of high and paranoia feeling, and pulse rate than the PMR group at baseline. After practicing PMR, but not after a control activity, smokers undergoing acute abstinence had significantly lower levels of cigarette craving, withdrawal symptoms, and systolic blood pressure than at baseline. After controlling for baseline differences, abstaining smokers using PMR had lower levels of cigarette craving, withdrawal symptoms, and systolic blood pressure than smokers who undertook a control activity.

CONCLUSIONS

PMR significantly reduces cigarette craving, withdrawal symptoms, and blood pressure in smokers undergoing acute abstinence. PMR may be used as an adjunct to cigarette dependency treatments.

Nicotine dependence, "background" and cue-induced craving and smoking in the laboratory

BACKGROUND

Nicotine dependence has been associated with higher "background" craving and smoking, independent of situational cues. Due in part to conceptual and methodological differences across past studies, the relationship between dependence and cue-reactivity (CR; e.g., cue-induced craving and smoking) remains unclear.

METHODS

207 daily smokers completed six pictorial CR sessions (smoking, negative affect, positive affect, alcohol, smoking prohibitions, and neutral). Individuals rated craving before (background craving) and after cues, and could smoke following cue exposure. Session videos were coded to assess smoking. Participants completed four nicotine dependence measures. Regression models assessed the relationship of dependence to cue-independent (i.e., pre-cue) and cue-specific (i.e., pre-post cue change for each cue, relative to neutral) craving and smoking (likelihood of smoking, latency to smoke, puff count).

RESULTS

Dependence was associated with background craving and smoking, but did not predict change in craving across the entire sample for any cue. Among alcohol drinkers, dependence was associated with greater increases in craving following the alcohol cue. Only one dependence measure (Wisconsin Inventory of Smoking Dependence Motives) was consistently associated with smoking reactivity (higher likelihood of smoking, shorter latency to smoke, greater puff count) in response to cues.

CONCLUSION

While related to cue-independent background craving and smoking, dependence is not strongly associated with laboratory cue-induced craving under conditions of minimal deprivation. Dependence measures that incorporate situational influences on smoking correlate with greater cue-provoked smoking. This may suggest independent roles for CR and traditional dependence as determinants of smoking, and highlights the importance of assessing behavioral CR outcomes.

Mood, mood regulation, and frontal systems functioning in current smokers, long-term abstinent ex-smokers, and never-smokers

Indices of mood, mood regulation, and executive functioning were examined in 61 current smokers who have smoked daily for at least one year, 36 ex-smokers who had not smoked a cigarette for at least one year, and 86 never-smokers. All participants completed the following measures online: Depression Anxiety Stress Scales (DASS-21), the Negative Mood Regulation (NMR) scale, the Frontal Systems Behavior Scale (FrSBe), the Fagerström Test for Cigarette Dependence (FTCD), and the Alcohol Use Disorders Identification Test (AUDIT). Multivariate analysis of variance (MANOVA) followed by Tukey post-hoc tests revealed significant differences (p < .01) such that current smokers indicated worse functioning than both ex-smokers and never-smokers on DASS, NMR, and FrSBe, as well as heavier drinking as measured by AUDIT. These differences remained significant even after controlling for AUDIT scores. Results most plausibly reflect a return to pre-smoking baseline brain function in long-term abstinent ex-smokers.

Effects of depressive symptoms on antecedents of lapses during a smoking cessation attempt: an ecological momentary assessment study

AIMS

To investigate pathways through which momentary negative affect and depressive symptoms affect risk of lapse during smoking cessation attempts.

DESIGN

Ecological momentary assessment was carried out during 2 weeks after an unassisted smoking cessation attempt. A 3-month follow-up measured smoking frequency.

SETTING

Data were collected via mobile devices in German-speaking Switzerland.

PARTICIPANTS

A total of 242 individuals (age 20-40, 67% men) reported 7112 observations.

MEASUREMENTS

Online surveys assessed baseline depressive symptoms and nicotine dependence. Real-time data on negative affect, physical withdrawal symptoms, urge to smoke, abstinence-related self-efficacy and lapses.

FINDINGS

A two-level structural equation model suggested that on the situational level, negative affect increased the urge to smoke and decreased self-efficacy (β = 0.20; β = -0.12, respectively), but had no direct effect on lapse risk. A higher urge to smoke (β = 0.09) and lower self-efficacy (β = -0.11) were confirmed as situational antecedents of lapses. Depressive symptoms at baseline were a strong predictor of a person's average negative affect (β = 0.35, all P < 0.001). However, the baseline characteristics influenced smoking frequency 3 months later only indirectly, through influences of average states on the number of lapses during the quit attempt.

CONCLUSIONS

Controlling for nicotine dependence, higher depressive symptoms at baseline were associated strongly with a worse longer-term outcome. Negative affect experienced during the quit attempt was the only pathway through which the baseline depressive symptoms were associated with a reduced self-efficacy and increased urges to smoke, all leading to the increased probability of lapses.

Predictors of smoking lapse in a human laboratory paradigm

RATIONALE

During a smoking quit attempt, a single smoking lapse is highly predictive of future relapse. While several risk factors for a smoking lapse have been identified during clinical trials, a laboratory model of lapse was until recently unavailable and, therefore, it is unclear whether these characteristics also convey risk for lapse in a laboratory environment.

OBJECTIVES

The primary study goal was to examine whether real-world risk factors of lapse are also predictive of smoking behavior in a laboratory model of smoking lapse.

METHODS

After overnight abstinence, 77 smokers completed the McKee smoking lapse task, in which they were presented with the choice of smoking or delaying in exchange for monetary reinforcement. Primary outcome measures were the latency to initiate smoking behavior and the number of cigarettes smoked during the lapse. Several baseline measures of smoking behavior, mood, and individual traits were examined as predictive factors.

RESULTS

Craving to relieve the discomfort of withdrawal, withdrawal severity, and tension level were negatively predictive of latency to smoke. In contrast, average number of cigarettes smoked per day, withdrawal severity, level of nicotine dependence, craving for the positive effects of smoking, and craving to relieve the discomfort of withdrawal were positively predictive of number of cigarettes smoked.

CONCLUSIONS

The results suggest that real-world risk factors for smoking lapse are also predictive of smoking behavior in a laboratory model of lapse. Future studies using the McKee lapse task should account for between subject differences in the unique factors that independently predict each outcome measure.

Predisposing, enabling and reinforcing factors associated with smoking relapse among hospital workers

OBJECTIVES

A better identification of the determinants of smoking relapse among hospital workers would be helpful in development of more effective interventions to decrease the frequency of relapses in this group. The aim of this study was to determine the predisposing enabling, and reinforcing factors associated with smoking relapse among workers at a university hospital.

METHODS

This was a case-control study based on a self-administered and structured questionnaire. Cases were all those workers who had relapsed after at least 6 months without smoking, and controls were ex-smokers without relapse for more than 6 months. We obtained the following information: sociodemographic and tobacco consumption characteristics and a list of predisposing, enabling and reinforcing factors.

RESULTS

There were 342 respondents: 114 cases and 228 controls. The variables significantly and independently associated with increased risk of relapse were smoking is my vice (OR=4.02), I'll be able to quit smoking whenever I want (OR=3.43), I have no intention to quit forever (OR=6.02), celebrations (OR=3.93) and weight gain (OR=10.61), while variables associated with lower risk were age (OR=0.88), health-care worker (OR=0.13), years of abstinence (OR=0.91), smoking is a useless habit (OR=0.19) and illness related to tobacco (OR=0.07).

CONCLUSIONS

Health programs against smoking in the hospital setting should include measures aimed at preventing relapse through behavioral support therapies and dietary control with particular attention to changes in factors related to lifestyle and false beliefs (predisposing factors).

Early lapses in a cessation attempt: lapse contexts, cessation success, and predictors of early lapse

INTRODUCTION

The great majority of smokers relapse when they make quit attempts. Therefore, understanding the process of relapse may guide the development of more effective smoking cessation or relapse prevention treatments. The goal of this research is to extend our understanding of the context of initial lapses that occur within 8 weeks of quitting by using more comprehensive assessments of context, a contemporary sample, and sophisticated analytic techniques.

METHODS

Participants from a randomized controlled smoking cessation trial completed baseline assessments of demographics and tobacco dependence, a daily smoking calendar to determine latency to lapse and relapse (7 consecutive days of smoking), and an assessment of initial lapse context (affect, location, activity, interpersonal, smoke exposure, and cigarette availability). Latent class analysis (LCA) was used to analyze the 6 early lapse (within the first 8 weeks; N = 551) context dimensions; logistic regression and Cox regression were used to relate context to cessation outcomes.

RESULTS

LCA revealed 5 distinct initial lapse context classes (talking, with friends, angry; social; alone; with spouse, angry; and with smoking spouse) that were differentially related to cessation outcome. The easy availability of cigarettes characterized almost 75% of lapses, but being with friends, drinking, and not being at home were associated with a lower likelihood of progression to relapse.

CONCLUSIONS

Early lapsing is highly related to ultimate relapse, and lapsing in frequently experienced contexts seemed most strongly linked with progression to full relapse.

Mood, mood regulation expectancies and frontal systems functioning in current smokers versus never-smokers in China and Australia

Indices of mood, mood regulation expectancies and everyday executive functioning were examined in adult current smokers and never-smokers of both genders in Australia (N = 97), where anti-smoking campaigns have dramatically reduced smoking prevalence and acceptability, and in China (N = 222), where smoking prevalence and public acceptance of smoking remain high. Dependent measures included the Depression Anxiety Stress Scales (DASS-21), the Negative Mood Regulation (NMR) expectancies scale, the Frontal Systems Behavior Scale (FrSBe), the Fagerström Test for Nicotine Dependence (FTND) and the Alcohol Use Disorders Identification Test (AUDIT). Multivariate analyses of covariance (MANCOVAs) controlling for demographic and recruitment related variables revealed highly significant differences between current smokers and never-smokers in both countries such that smokers indicated worse moods and poorer functioning than never-smokers on all dependent measures. Chinese smokers scored significantly worse on all dependent measures than Australian smokers whereas Chinese and Australian never-smokers did not differ on any of the same measures. Although nicotine dependence level as measured by FTND was significantly higher in Chinese than Australian smokers and was significantly correlated with all other dependent measures, inclusion of FTND scores as another covariate in MANCOVA did not eliminate the highly significant differences between Chinese and Australian smokers. Results are interpreted in light of the relative ease of taking up and continuing smoking in China compared to Australia today.

Brief, instructional smokeless tobacco use among cigarette smokers who do not intend to quit: a pilot randomized clinical trial

INTRODUCTION

Low-nitrosamine smokeless tobacco (SLT) may have efficacy for smoking reduction and cessation, but its public health impact depends on how smokers use it.

METHODS

This pilot study explored brief, instructional low-nitrosamine SLT use among smokers unmotivated to quit. Participants (N = 57) were randomized to either a free 2-week supply of Camel Snus group or a no-supply group. Of those randomized to use Camel Snus, half were told to use it to cope with smoking restrictions (Snus to Cope), and the remaining half were advised to use it to reduce smoking (Snus to Reduce). Participants were assessed before, during, and immediately after the intervention.

RESULTS

Many Snus to Cope and Snus to Reduce participants reported daily use of Camel Snus, although the amount of use was low. Snus to Cope (18.4%) and Snus to Reduce (37.6%) participants reported a decline in number of cigarettes used per day, which was not reported by the control participants (p < .001). Intention to quit smoking and intention to quit all tobacco use (ps < .001) increased to a greater extent among Snus to Cope and Snus to Reduce participants than among control participants.

CONCLUSIONS

This study replicates previous work that shows that low-nitrosamine SLT use can lead to reduced smoking and increased intention to quit, and it adds direct evidence to suggest that the function of low-nitrosamine SLT use-either to cope with smoking restrictions or to reduce smoking-can have a differential impact on smoking behavior. Overall, the results highlight the importance of messaging and, more specifically, marketing of low-nitrosamine SLT to smokers.

Low dose nicotine and antagonism of β2 subunit containing nicotinic acetylcholine receptors have similar effects on affective behavior in mice

Nicotine leads to both activation and desensitization (inactivation) of nicotinic acetylcholine receptors (nAChRs). This study tested the hypothesis that nicotine and a selective antagonist of β2*nAChRs would have similar effects on affective behavior. Adult C57BL/6J male mice were tested in a conditioned emotional response (CER) assay which evaluates the ability of an aversive stimulus to inhibit goal-directed behavior. Mice lever-pressed for a saccharin reinforcer according to a variable schedule of reinforcement during sessions in which two presentations of a compound light/tone conditioned stimulus (CS) co-terminated with a 0.1 or 0.3 mA, 0.5 s footshock unconditioned stimulus (US). During testing in the absence of the US, mice received doses of i.p. nicotine (0, 0.0032, 0.01, 0.032, 0.1 mg/kg) or a selective β2 subunit containing nAChR (β2*nAChR) antagonist dihydro-beta-erythroidine (0, 0.1, 0.3, 1.0, 3.0 mg/kg DHβE). There was a dose-dependent effect of nicotine revealing that only low doses (0.01, 0.032 mg/kg) increased CER suppression ratios (SR) in these mice. DHβE also dose-dependently increased SR at the 3 mg/kg dose. In ethological measures of fear-/anxiety-like behavior, these doses of nicotine and DHβE significantly reduced digging behavior in a marble burying task and 0.3 mg/kg DHβE promoted open-arm activity in the elevated plus maze. Doses of nicotine and DHβE that altered affective behavior had no effect on locomotor activity. Similar to previous reports with anxiolytic drugs, low dose nicotine and DHβE reversed SR in a CER assay, decreased digging in a marble burying assay and increased open arm activity in the elevated plus maze. This study provides evidence that inactivation of β2*nAChRs reduces fear-like and anxiety-like behavior in rodents and suggests that smokers may be motivated to smoke in part to desensitize their β2*nAChRs. These data further identify β2*nAChR antagonism as a potential therapeutic strategy for relief of negative affect and anxiety.

Adolescent first lapse following smoking cessation: situation characteristics, precipitants and proximal influences

Despite increased attention to adolescent smoking cessation, little is known about adolescent relapse following a quit attempt. To address this issue, the present study was designed to provide initial information regarding the characteristics of adolescent lapses to smoking following abstinence. Included in the present study were 204 adolescent participants in four independent smoking cessation trials. For the full sample, participants averaged 15.99 (1.27) years of age; 56% were female and 78% were white. Lapse characteristics and precipitants were assessed using the Adolescent Smoking Relapse Review. Three domains of the lapse experience were assessed: lapse situation characteristics, precipitants of use in the situation, and proximal influences (i.e., potential precipitants occurring on the same day, prior to the lapse situation). Participant reports indicated that the modal lapse situation occurred in the evening while socializing with friends at home. Urges or cravings and social pressure were commonly endorsed as occurring in lapse situations. The most frequently reported proximal influence was desire for a cigarette, followed by abstinence-violation cognitions (okay to smoke occasionally, wanted to see what it would be like) and negative emotions. The findings indicate that a broad range of factors appear to influence adolescent smoking lapse and commend the value of incorporating content relevant to managing social and affective cues, strategies for inhibiting the prepotent response to ask for a cigarette, addressing cognitions regarding the difficulty of not smoking (i.e., cessation expectancies) and combating perceptions of the ability to smoke occasionally.

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.

Emotion identification and tension in female patients with borderline personality disorder

OBJECTIVES

This study investigates the identification of emotions in patients with borderline personality disorder (BPD), when compared with mentally healthy control subjects. The inability to identify different emotions is considered as an essential component of affect dysregulation in BPD that has rarely been empirically investigated.

METHODS

In this study, 30 female borderline patients and 28 healthy control participants received a handheld-PC for a 24-hour period that reminded them hourly to enter data.

RESULTS

When compared with the control group, patients showed pronounced difficulties in emotion identification. Moreover, the data revealed a significant relationship between difficulties in identifying emotions and levels of aversive inner tension for BPD patients, but not for control subjects.

CONCLUSIONS

Results indicate that the inability to identify different emotions is a problem that characterizes borderline patients in real-life situations. Treatment programs should, therefore, focus on the improvement of emotion identification and regulation.

Adolescents' expectancies for smoking to regulate affect predict smoking behavior and nicotine dependence over time

AIMS

Mounting evidence suggests that individuals smoke, in part, to regulate affective experience (e.g., tension reduction, mood enhancement). Implicit in such motives is the expectancy or belief that smoking will decrease negative affect and increase positive affect. The contribution of cognitively-driven expectancies to the initiation and continuation of smoking during adolescence remains largely uninvestigated. The current study examined the influence of negative affect relief expectancies (NAREs) for smoking on smoking behavior and nicotine dependence using longitudinal data from a study on the emotional and social contexts of youth smoking.

METHODS

Participants were 568 adolescents with smoking experience (mean age 15.67, 56.7% female). Three separate mixed regression models were estimated to determine the relative contribution of NAREs to smoking behavior and nicotine dependence measured at 4 time points over 2 years.

RESULTS

NAREs for smoking influenced all smoking outcomes at baseline and predicted increases in smoking behavior and nicotine dependence over time, even after controlling for anxious and depressive symptoms and baseline nicotine dependence.

CONCLUSIONS

Outcome expectancies for affect management emerged as an important risk factor for smoking escalation and the development of nicotine dependence during adolescence. The present findings highlight the potential importance of cognitively-driven expectancies as a risk factor for smoking escalation during this critical developmental period.

Behavioral economic analysis of cue-elicited craving for alcohol

AIMS

Craving as a motivational determinant of drug use remains controversial because of ambiguous empirical findings. A behavioral economic approach may clarify the nature of craving, theorizing that subjective craving functionally reflects an acute increase in a drug's value. The current study tested this hypothesis via a multidimensional assessment of alcohol demand over the course of an alcohol cue reactivity procedure.

DESIGN

One-way within-subjects design.

SETTING

Human laboratory environment.

PARTICIPANTS

Heavy drinkers (n = 92) underwent exposures to neutral (water) cues followed by personalized alcohol cues.

ASSESSMENTS

Participants were assessed for craving, alcohol demand, affect, and salivation following each exposure.

FINDINGS

Alcohol versus neutral cues significantly increased craving and multiple behavioral economic measures of the relative value of alcohol, including alcohol consumption under conditions of zero cost (intensity), maximum expenditure on alcohol (O(max)), persistence in drinking to higher prices (breakpoint) and proportionate price insensitivity (normalized P(max)). Craving was significantly correlated with demand measures at levels ranging from 0.21-0.43.

CONCLUSIONS

These findings support the potential utility of a behavioral economic approach to understanding the role of environmental stimuli in alcohol-related decision making. Specifically, they suggest that the behavioral economic indices of demand may provide complementary motivational information that is related to though not entirely redundant with measures of subjective craving.

Three versions of Perceived Stress Scale: validation in a sample of Chinese cardiac patients who smoke

Background

Smoking causes heart disease, the major cause of death in China and Hong Kong. Stress is one major trigger of smoking and relapse, and understanding stress among smoking cardiac patients can therefore help in designing effective interventions to motivate them to quit. The objective of this study was to examine the psychometric properties of the Perceived Stress Scale (PSS), and to compare the appropriateness of the three versions of the scale (PSS-14, PSS-10, and PSS-4) among Chinese cardiac patients who were also smokers.

Methods

From March 2002 to December 2004, 1860 cardiac patients who smoked were recruited at the cardiac outpatient clinics of ten acute hospitals in Hong Kong, and 1800 questionnaires were analysed. Participants completed a questionnaire including the PSS, nicotine dependence and certain demographic variables. The psychometric properties of the PSS were investigated: construct validity using confirmatory factor analysis, reliability using Cronbach's alpha and concurrent validity by examining the relationship with smoking- and health-related variables.

Results

For all the three versions of the PSS, confirmatory factor analyses corroborated the 2-factor structure of the scale, with the positive and negative factors correlating significantly and negatively to a moderate extent (r < -0.5), and high Cronbach's alpha values for the two subscales (alpha > 0.5). All the correlations of the two subscales and the smoking- and health-related variables were statistically significant and in the expected directions although of small magnitudes, except daily cigarette consumption.

Conclusions

The findings confirmed the satisfactory psychometric properties of all three Chinese versions of PSS. We recommend the use of PSS-10 for research which focuses on the two components of perceived stress, as it shows a higher reliability; and the use of PSS-4 if such partition is not essential and space for multiple measures is limited.

Alcohol use and initial smoking lapses among heavy drinkers in smoking cessation treatment

INTRODUCTION

This study examined alcohol use and its association with initial smoking lapses among heavy nondependent drinkers in smoking cessation treatment.

METHODS

Participants were 236 heavy drinking smokers in a randomized clinical trial testing the efficacy of incorporating brief alcohol intervention into smoking cessation treatment.

RESULTS

Of the 178 participants who reported a smoking lapse, 41.5% lapsed when drinking alcohol. Those who had alcohol-involved lapses had significantly lower tobacco dependence severity and drank more drinks per week than those who had non-alcohol-involved lapses. The majority of alcohol-involved lapses were in a bar/restaurant, with other people, and when they were in a happy/good mood. In survival analyses with alcohol consumption as a time-varying covariate, moderate drinking days were associated with almost four times greater risk of smoking lapse than non-drinking days, and heavy drinking doubled the risk of lapsing compared with moderate drinking.

DISCUSSION

Results suggest that alcohol-related lapses are qualitatively different from lapses that do not involve alcohol. Furthermore, among heavy drinkers in cessation treatment, even moderate alcohol use is associated with increased risk of smoking, with heavy drinking further increasing the risk. Smoking cessation treatments for heavy alcohol drinkers should highlight the lapse risk associated with any alcohol consumption and with heavy drinking during a quit smoking attempt.

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.

Predicting lapse when stopping smoking among pregnant and non-pregnant women

This study aimed to investigate factors predicting lapse among pregnant and non-pregnant women when trying to stop smoking. A total of 40 women, pregnant and non-pregnant, were investigated over a 2-week period when trying to stop smoking. One-quarter of the women lapsed every day. Not being pregnant was a significant predictor for the occurrence of any lapse during the time period, whereas age, number of years of smoking, number of earlier attempts to stop smoking, and number of cigarettes smoked per day did not predict lapse. There was a four times higher risk for lapse in non-pregnant compared with pregnant women. Being pregnant gives an opportunity to help stop smoking with a considerably lower risk of lapse compared with non-pregnant women.

Do resisted temptations during smoking cessation deplete or augment self-control resources?

A resource depletion model of self-control posits that for some period following performance of a task requiring self-control, self-control will be reduced and thus less available for use in a subsequent task. Using 2 substantial data sets collected in real time from individuals who were trying to quit smoking (1,660 and 9,516 temptation episodes collected from 61 and 248 individuals, respectively), we evaluated this model by testing the hypotheses that the number and length of resisted temptations and the intensity of the most recently reported urge during the prior 4 hr predict decreased self-control and increased likelihood of lapsing. Survival and multilevel regression modeling showed that contrary to the hypothesis, the number of recently resisted temptations predicted a lower risk of lapsing in both samples. Duration of resisted temptations had no significant effect in either sample. Intensity of most recently reported urge predicted lapsing in 1 data set but not in the other. Overall, there was little support for the resource depletion model. The protective effect of successfully resisting temptations was an unexpected but provocative finding.

Does the reaction of abstaining smokers to the smell of other people's cigarettes predict relapse?

AIMS

Recent ex-smokers report a range of reactions to other people's cigarette smoke. We examined the hypothesis that those who find the smell of smoke pleasant and tempting are more likely to relapse than those who have a neutral or even negative reaction to it.

DESIGN

A total of 1110 consecutive patients who attended for smoking cessation treatment and achieved at least 1 week of validated abstinence provided weekly ratings of their reactions to other people's cigarette smoke together with routine baseline measures and weekly ratings of withdrawal discomfort [measured on the Mood and Physical Symptom Scale (MPPS)].

FINDINGS

Twenty-three per cent of the sample found the smell of other people's cigarette smoke during their first week of abstinence pleasant, and 54% found it tempting. There was only a modest correlation between the two variables. Finding the smoke pleasant was not related to smoking status in the following week, but finding the smoke tempting predicted relapse. Ratings of temptation were related to the severity of withdrawal discomfort and to dependence. Entering MPPS ratings of urges to smoke in the given week into regression analysis resulted in the general urges to smoke, rather than urges elicited by other people's smoke, becoming a significant predictor of smoking status in the following week. In patients who maintained continuous abstinence throughout 4 weeks of treatment the pleasantness ratings remained stable, while the ratings of temptation steadily decreased.

CONCLUSIONS

In abstaining smokers, the like or dislike of other people's smoke is not related to relapse. The temptation to smoke elicited by other people's smoke is related to outcome, but only as an indicator of a general 'temptation threshold'. Patients who find other people's smoke tempting can be reassured that this reaction will gradually decrease.

Time to first cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence

An inability to maintain abstinence is a key indicator of tobacco dependence. Unfortunately, little evidence exists regarding the ability of the major tobacco dependence measures to predict smoking cessation outcome. This paper used data from four placebo-controlled smoking cessation trials and one international epidemiological study to determine relations between cessation success and the Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index, the Nicotine Dependence Syndrome Scale, and the Wisconsin Inventory of Smoking Dependence Motives. Results showed that much of the predictive validity of the FTND could be attributed to its first item, time to first cigarette in the morning, and this item had greater validity than any other single measure. Thus the time-to-first-cigarette item appears to tap a pattern of heavy, uninterrupted, and automatic smoking and may be a good single-item measure of nicotine dependence.