Mood disturbance fails to resolve across 31 days of cigarette abstinence in women

Effects of a 7-Day Pornography Abstinence Period on Withdrawal-Related Symptoms in Regular Pornography Users: A Randomized Controlled Study

Little is known about whether withdrawal-like symptoms manifest when regular pornography users attempt to abstain from pornography. The present study used a randomized controlled design to examine whether (1) negative abstinence effects that may be potentially reflective of withdrawal-related symptoms manifest when a non-clinical sample of regular pornography users attempt to abstain from pornography for a 7-day period and (2) these negative abstinence effects would only manifest (or manifest more strongly) for those with higher levels of problematic pornography use (PPU). A total of 176 undergraduate students (64.2% female) who were regular pornography users (defined as having used pornography ≥ three times a week in the past 4 weeks) were randomly assigned to an abstinence group (instructed to attempt abstinence from pornography for 7 days, n = 86) or a control group (free to watch pornography as usual, n = 90). Participants completed measures of craving, positive and negative affect, and withdrawal symptoms at baseline and each night of the 7-day period. Contrary to the confirmatory hypotheses, there were no significant main effects of group (abstinence vs. control) or group × PPU interaction effects on any of the outcome measures, controlling for baseline scores. These findings indicate that no evidence of withdrawal-related symptoms was found for abstaining participants, and this was not dependent on level of PPU. However, exploratory analyses showed a significant three-way interaction (group × PPU × past 4-week frequency of pornography use [FPU]) on craving, where an abstinence effect on craving was found at high levels of PPU only once past 4-week FPU reached the threshold of daily use. While these exploratory findings should be interpreted with caution, they suggest that abstinence effects could potentially manifest when there is a combination of high PPU and high FPU-a hypothesis that warrants investigation in future prospective abstinence studies.

Effects of cigarette abstinence on negative and positive affect by depression symptom levels: A lab study

BACKGROUND

High negative affect and low positive affect are key depression-related states that may be greater following acute tobacco abstinence. This study aimed to test associations between depression symptom levels and acute tobacco abstinence with negative affect and positive affect.

METHODS

Following a baseline session, participants attended two counterbalanced laboratory sessions (non-abstinent, abstinent) and completed measures of positive and negative affect at rest (i.e., when not completing a task) and during a film clip task.

RESULTS

Individuals with elevated depression symptoms had higher negative affect and lower positive affect at rest and during the film clip task compared to individuals with low depression symptoms. There was no interaction of depression symptom levels and abstinence on negative and positive affect at rest. There was an interaction of depression symptom level and abstinence on negative and positive affect during the film clip task. Individuals with elevated depression showed significant differences in positive and negative affect between the abstinent and non-abstinent session, but no significant abstinence effects were noted in individuals with low depression symptoms.

LIMITATIONS

The study included a non-treatment seeking sample and experimentally induced acute cigarette abstinence. We excluded for the use of smoking cessation medications that are also used to treat depression, classified depression levels using dichotomized CES-D scores, and used self-report measures of affect.

CONCLUSIONS

Results of this study suggest individuals with elevated depression symptoms who smoke experience elevated negative affect and lower positive affect and cigarette abstinence may uniquely alter affective reactivity in individuals with elevated depression symptoms.

Anhedonia in Nicotine Dependence

Prior findings indicate that trait anhedonia enhances the likelihood of becoming a tobacco smoker, and preliminary evidence suggests that smoking abstinence leads to anhedonic states in some individuals and situations, and nicotine administration reduces anhedonic states. Nevertheless, many vital questions exist concerning relationships between anhedonia and nicotine dependence, including situational and individual difference factors that may moderate the strength of these associations. This chapter provides a critical review of the literature assessing relationships of anhedonia to nicotine dependence and the effects of acute nicotine through the lenses of the Research Domain Criteria's (RDoC) Positive Valence Systems (NIMH, RDoC changes to the matrix (CMAT) workgroup update: proposed positive valence domain revisions. A report by the national advisory mental health council workgroup on changes to the research domain criteria matrix, 2018) and the Situation x Trait Affective Response (STAR) model of nicotine's effects and nicotine dependence (Gilbert, Smoking individual differences, psychopathology, and emotion. Taylor and Francis, Washington, DC, 1995; Gilbert, Hum Psychopharmacol Clin Exp 12:S89-S102, 1997). The effects of nicotine and nicotine withdrawal on subjective, behavioral, and brain indices vary across the three RDoC Positive Valences Systems (Reward Responsiveness, Reward Learning, and Reward Valuation) in a manner that supports the research and potential clinical utility of using RDoC criteria and the STAR model to guide research and clinical innovation. We provide a revision of the STAR model that incorporates the three RDoC Positive Valence Systems with evidence that nicotine's effects on hedonic and affective processes vary as a function of the dominance/salience of (1) situational hedonic and affective cues and task/active coping cues, and (2) state executive functioning level/capacity and state reward sensitivity such that these effects of nicotine are maximal during states of suboptimal cognitive functioning and reward sensitivity, combined with low situational stimulus salience and low task-related cues/demands.

GABAB receptors blockage modulates somatic and aversive manifestations induced by nicotine withdrawal

There is substantial evidence that GABA_B agonist, baclofen, prevents somatic and motivational responses induced by nicotine withdrawal and may target drug cue vulnerabilities in humans. In this context, we explored different aspects associated with the possible mechanisms whereby the GABA_B receptors might influence nicotine withdrawal. Male mice received nicotine (2.5 mg/kg, s.c.) 4 times daily, for 7 consecutive days. Nicotine-treated mice received the nicotinic acetylcholine receptor antagonist, mecamylamine (MEC, 2 or 3.5 mg/kg, s.c.), to precipitate the withdrawal state. A second group of dependent mice received 2-hydroxysaclofen (GABA_B receptor antagonist, 1 mg/kg, s.c.) before MEC-precipitated abstinence. Somatic signs of nicotine withdrawal were measured for 30 min. Anxiogenic-like response associated to nicotine withdrawal was assessed by the elevated plus maze test. The dysphoric/aversive effect induced by nicotine withdrawal was evaluated using conditioned place aversion paradigm. Dopamine, serotonin and its metabolites concentrations were determined by HPLC in the striatum, cortex and hippocampus. Finally, α4β2 nicotinic acetylcholine receptor density was determined in several brain regions using autoradiography assays. The results showed that MEC-precipitated nicotine withdrawal induced somatic manifestations, anxiogenic-like response and dysphoric/aversive effect, and 2-hydroxysaclofen potentiated these behavioral responses. Additionally, 2-hydroxysaclofen was able to change striatal dopamine levels and α4β2 nicotinic acetylcholine receptor density, both altered by MEC-precipitated nicotine withdrawal. These findings provide important contributions to elucidate neurobiological mechanisms implicated in nicotine withdrawal. We suggest that GABA_B receptor activity is necessary to control alterations induced by nicotine withdrawal, which supports the idea of targeting GABA_B receptors to treat tobacco addiction in humans.

Genetic and Depressive Traits Moderate the Reward-Enhancing Effects of Acute Nicotine in Young Light Smokers

INTRODUCTION

Rates of light smoking have increased in recent years and are associated with adverse health outcomes. Reducing light smoking is a challenge because it is unclear why some but not others, progress to heavier smoking. Nicotine has profound effects on brain reward systems and individual differences in nicotine's reward-enhancing effects may drive variability in smoking trajectories. Therefore, we examined whether a genetic risk factor and personality traits known to moderate reward processing, also moderate the reward-enhancing effects of nicotine.

METHODS

Light smokers (n = 116) performed a Probabilistic Reward Task to assess reward responsiveness after receiving nicotine or placebo (order counterbalanced). Individuals were classified as nicotine dependence 'risk' allele carriers (rs16969968 A-allele carriers) or non-carriers (non-A-allele carriers), and self-reported negative affective traits were also measured.

RESULTS

Across the sample, reward responsiveness was greater following nicotine compared to placebo (p = 0.045). For Caucasian A-allele carriers but not non-A-allele carriers, nicotine enhanced reward responsiveness compared to placebo for those who received placebo first (p = 0.010). Furthermore, for A-allele carriers but not non-A-allele carriers who received nicotine first, the enhanced reward responsiveness in the nicotine condition carried over to the placebo condition (p < 0.001). Depressive traits also moderated the reward-enhancing effects of nicotine (p = 0.010) and were associated with blunted reward responsiveness following placebo but enhanced reward responsiveness following nicotine.

CONCLUSION

These findings suggest that individual differences in a genetic risk factor and depressive traits alter nicotine's effect on reward responsiveness in light smokers and may be important factors underpinning variability in smoking trajectories in this growing population.

IMPLICATIONS

Individuals carrying genetic risk factors associated with nicotine dependence(rs16969968 A-allele carriers) and those with higher levels of depressive personality traits, showmore pronounced increases in reward learning following acute nicotine exposure. These findingssuggest that genetic and personality factors may drive individual differences in smoking trajectoriesin young light smokers by altering the degree to which nicotine enhances reward processing.

CLINICAL TRIAL REGISTRATION

NCT02129387 (pre-registered hypothesis: www.clinicaltrials.gov).

APOE genotype influences P3b amplitude and response to smoking abstinence in young adults

RATIONALE

There is strong evidence that nicotine can enhance cognitive functions and growing evidence that this effect may be larger in young healthy APOE ε4 carriers. However, the moderating effects of the APOE ε4 allele on cognitive impairments caused by nicotine deprivation in chronic smokers have not yet been studied with brain indices.

OBJECTIVE

We sought to determine whether young female carriers of the APOE ε4 allele, relative to noncarriers, would exhibit larger abstinence-induced decreases in P3b amplitude during a two-stimulus auditory oddball task.

METHODS

We compared parietal P3bs in female chronic smokers with either APOE ε3/ε3 (n = 54) or ε3/ε4 (n = 20) genotype under nicotine-sated conditions and after 12-17-h nicotine deprivation.

RESULTS

Nicotine deprivation significantly reduced P3b amplitudes in APOE ε4 carriers, but not in APOE-ε3/ε3 individuals, such that the difference seen prior to nicotine deprivation was eliminated.

CONCLUSIONS

The results suggest that subjects with the APOE ε4 allele are more sensitive to nicotine, which could influence smoking patterns, the risk for nicotine dependence, and the cognitive effects of nicotine use in these individuals.

Smoking cessation for improving mental health

BACKGROUND

There is a common perception that smoking generally helps people to manage stress, and may be a form of 'self-medication' in people with mental health conditions. However, there are biologically plausible reasons why smoking may worsen mental health through neuroadaptations arising from chronic smoking, leading to frequent nicotine withdrawal symptoms (e.g. anxiety, depression, irritability), in which case smoking cessation may help to improve rather than worsen mental health.

OBJECTIVES

To examine the association between tobacco smoking cessation and change in mental health.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and the trial registries clinicaltrials.gov and the International Clinical Trials Registry Platform, from 14 April 2012 to 07 January 2020. These were updated searches of a previously-conducted non-Cochrane review where searches were conducted from database inception to 13 April 2012.  SELECTION CRITERIA: We included controlled before-after studies, including randomised controlled trials (RCTs) analysed by smoking status at follow-up, and longitudinal cohort studies. In order to be eligible for inclusion studies had to recruit adults who smoked tobacco, and assess whether they quit or continued smoking during the study. They also had to measure a mental health outcome at baseline and at least six weeks later.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods for screening and data extraction. Our primary outcomes were change in depression symptoms, anxiety symptoms or mixed anxiety and depression symptoms between baseline and follow-up. Secondary outcomes  included change in symptoms of stress, psychological quality of life, positive affect, and social impact or social quality of life, as well as new incidence of depression, anxiety, or mixed anxiety and depression disorders. We assessed the risk of bias for the primary outcomes using a modified ROBINS-I tool.  For change in mental health outcomes, we calculated the pooled standardised mean difference (SMD) and 95% confidence interval (95% CI) for the difference in change in mental health from baseline to follow-up between those who had quit smoking and those who had continued to smoke. For the incidence of psychological disorders, we calculated odds ratios (ORs) and 95% CIs. For all meta-analyses we used a generic inverse variance random-effects model and quantified statistical heterogeneity using I2. We conducted subgroup analyses to investigate any differences in associations between sub-populations, i.e. unselected people with mental illness, people with physical chronic diseases. We assessed the certainty of evidence for our primary outcomes (depression, anxiety, and mixed depression and anxiety) and our secondary social impact outcome using the eight GRADE considerations relevant to non-randomised studies (risk of bias, inconsistency, imprecision, indirectness, publication bias, magnitude of the effect, the influence of all plausible residual confounding, the presence of a dose-response gradient).

MAIN RESULTS

We included 102 studies representing over 169,500 participants. Sixty-two of these were identified in the updated search for this review and 40 were included in the original version of the review.  Sixty-three studies provided data on change in mental health, 10 were included in meta-analyses of incidence of mental health disorders, and 31 were synthesised narratively.  For all primary outcomes, smoking cessation was associated with an improvement in mental health symptoms compared with continuing to smoke: anxiety symptoms (SMD -0.28, 95% CI -0.43 to -0.13; 15 studies, 3141 participants; I2 = 69%; low-certainty evidence); depression symptoms: (SMD -0.30, 95% CI -0.39 to -0.21; 34 studies, 7156 participants; I2 = 69%' very low-certainty evidence);  mixed anxiety and depression symptoms (SMD -0.31, 95% CI -0.40 to -0.22; 8 studies, 2829 participants; I2 = 0%; moderate certainty evidence).  These findings were robust to preplanned sensitivity analyses, and subgroup analysis generally did not produce evidence of differences in the effect size among subpopulations or based on methodological characteristics. All studies were deemed to be at serious risk of bias due to possible time-varying confounding, and three studies measuring depression symptoms were judged to be at critical risk of bias overall. There was also some evidence of funnel plot asymmetry. For these reasons, we rated our certainty in the estimates for anxiety as low, for depression as very low, and for mixed anxiety and depression as moderate. For the secondary outcomes, smoking cessation was associated with an improvement in symptoms of stress (SMD -0.19, 95% CI -0.34 to -0.04; 4 studies, 1792 participants; I2 = 50%), positive affect (SMD 0.22, 95% CI 0.11 to 0.33; 13 studies, 4880 participants; I2 = 75%), and psychological quality of life (SMD 0.11, 95% CI 0.06 to 0.16; 19 studies, 18,034 participants; I2 = 42%). There was also evidence that smoking cessation was not associated with a reduction in social quality of life, with the confidence interval incorporating the possibility of a small improvement (SMD 0.03, 95% CI 0.00 to 0.06; 9 studies, 14,673 participants; I2 = 0%). The incidence of new mixed anxiety and depression was lower in people who stopped smoking compared with those who continued (OR 0.76, 95% CI 0.66 to 0.86; 3 studies, 8685 participants; I2 = 57%), as was the incidence of anxiety disorder (OR 0.61, 95% CI 0.34 to 1.12; 2 studies, 2293 participants; I2 = 46%). We deemed it inappropriate to present a pooled estimate for the incidence of new cases of clinical depression, as there was high statistical heterogeneity (I2 = 87%).

AUTHORS' CONCLUSIONS

Taken together, these data provide evidence that mental health does not worsen as a result of quitting smoking, and very low- to moderate-certainty evidence that smoking cessation is associated with small to moderate improvements in mental health.  These improvements are seen in both unselected samples and in subpopulations, including people diagnosed with mental health conditions. Additional studies that use more advanced methods to overcome time-varying confounding would strengthen the evidence in this area.

Nicotine patch for cannabis withdrawal symptom relief: a randomized controlled trial

RATIONALE

Given that tetrahydrocannabinol (THC) and nicotine have similar effects on negative affect (NA), we hypothesized that a 7-mg nicotine patch (NP) would reduce NA-related cannabis (CAN) withdrawal symptoms in cannabis-dependent (CD) individuals who were not nicotine dependent.

OBJECTIVE

We sought to determine whether NP reduces NA across 15 days of CAN abstinence in two groups: non-tobacco smokers (NTS) and light tobacco smokers (LTS).

METHODS

CD participants (N = 127; aged 18-35) who used CAN at least 5 times/week for the past 12 + months were randomized to (1) NP or (2) a placebo patch (PP) and received $300 for sustained biochemically verified CAN abstinence. Of those randomly assigned, 52 of 63 NP, and 56 of 64 PP maintained biochemically verified CAN abstinence and 51 NP and 50 PP participants complied with all aspects of the study. Affect and other withdrawal symptoms were measured every 48 h across 15 days of CAN abstinence.

RESULTS

After controlling for age, tobacco use, baseline THC concentration, and baseline measurements of the dependent variable, NP reduced NA symptoms across the 15-day treatment relative to PP. Differences in NA and CAN withdrawal symptoms were not moderated by tobacco user status.

CONCLUSIONS

The findings provide the first evidence that NP may be able to attenuate NA-related withdrawal symptoms in individuals with cannabis use disorder who are not heavy users of tobacco or nicotine.

CLINICAL TRIALS REGISTRY

NCT01400243 http://www.clinicaltrials.gov.

Smoking abstinence symptoms across 67 days compared with randomized controls-Moderation by nicotine replacement therapy, bupropion, and negative-affect traits

Accurate knowledge of negative affect (NA)-related smoking abstinence symptoms (SAS) severity and duration and their moderation by pharmacotherapy and NA-related personality traits is critical for efficacious treatments given that elevated state and trait NA are predictors of relapse. However, SAS severity, duration, and moderation are not well characterized. To date, the longest randomized controlled trial (RCT) of NA-related SAS using randomized delayed-quit smoking controls only examined symptoms across 45 days, despite clinical evidence that SAS may last longer. The present RCT assessed SAS across 67 days in dependent smokers (N = 95) who were randomized either to quit or to delay quitting for the course of the trial. The quit group was further randomized to receive either nicotine replacement therapy (NRT), bupropion (BUP), or placebo. Abstinence-related increases in anger-irritability, depressive, anxiety, and general NA symptoms did not resolve relative to the delayed quit group (DQG) levels across the 67 days in any of the 3 quit groups, though craving fell to below DQG and prequit levels. While NRT attenuated Day 3 SAS relative to BUP and placebo, BUP and NRT generally did not reduce SAS. High scores on trait measures of NA/neuroticism predicted greater increases in and duration of NA-related SAS, potentially indicating that smoking abstinence unmasks affective symptoms. Positive affect was not impacted by abstinence or treatment. The results support the views that (a) prequit baseline values are not a valid index of NA SAS recovery, and (b) on average, NA-related SAS take longer than 67 days to resolve. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mental health disorders and alcohol use are associated with increased likelihood of smoking relapse among people living with HIV attending routine clinical care

BACKGROUND

People living with HIV (PLWH) have a high level of interest in quitting smoking, but only a small proportion have sustainable abstinence 6 months after cessation. Few investigations have focused on relapse to smoking among PLWH. In this investigation, we evaluated the prevalence of relapse after smoking cessation and the characteristics associated with smoking relapse using a retrospective, longitudinal cohort of PLWH during an eight-year observation.

METHODS

All patients aged ≥19 years that reported current smoking during the study period and then reported not smoking on a subsequent tobacco use questionnaire (quitters) were eligible for the study. In addition, patients required at least one subsequent follow-up visit after quitting where smoking status was again reported to allow for assessment of relapse. A Cox proportional hazard model was fit to evaluate factors associated with smoking relapse in PLWH attending routine clinical care.

RESULTS

Of the 473 patients who quit smoking in the study, 51% relapsed. In multivariable analysis, factors significantly associated with a higher likelihood of relapse were anxiety symptoms (HR = 1.55, 95% CI [1.11, 2.17]) and at-risk alcohol use (HR = 1.74, 95% CI [1.06, 2.85]), whereas antiretroviral therapy (ART) adherence (HR = 0.65, 95% CI [0.49, 0.99]) and longer time in care (HR = 0.94, 95% CI [0.91, 0.98]) were associated with a reduced likelihood of relapse after cessation.

CONCLUSION

Our study underscores the high prevalence of smoking relapse that exists among PLWH after they quit smoking. Successful engagement in mental health care may enhance efforts to reduce relapse in the underserved populations of PLWH.

Incentives for smoking cessation

BACKGROUND

Financial incentives, monetary or vouchers, are widely used in an attempt to precipitate, reinforce and sustain behaviour change, including smoking cessation. They have been used in workplaces, in clinics and hospitals, and within community programmes.

OBJECTIVES

To determine the long-term effect of incentives and contingency management programmes for smoking cessation.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The most recent searches were conducted in July 2018.

SELECTION CRITERIA

We considered only randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community, work-, clinic- or institution-based), and also studies in pregnant smokers.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant women we used abstinence measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenzel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations.

MAIN RESULTS

Thirty-three mixed-population studies met our inclusion criteria, covering more than 21,600 participants; 16 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 10 to be at high risk of bias, with the rest at unclear risk. Twenty-four of the trials were run in the USA, two in Thailand and one in the Phillipines. The rest were European. Incentives offered included cash payments or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.49 (95% CI 1.28 to 1.73; 31 RCTs, adjusted N = 20,097; I² = 33%). Results were not sensitive to the exclusion of six studies where an incentive for cessation was offered at long-term follow up (result excluding those studies: RR 1.40, 95% CI 1.16 to 1.69; 25 RCTs; adjusted N = 17,058; I² = 36%), suggesting the impact of incentives continues for at least some time after incentives cease.Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between USD 45 and USD 1185. There was no clear direction of effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits.We included 10 studies of 2571 pregnant women. We judged two studies to be at low risk of bias, one at high risk of bias, and seven at unclear risk. When pooled, the nine trials with usable data (eight conducted in the USA and one in the UK), delivered an RR at longest follow-up (up to 24 weeks post-partum) of 2.38 (95% CI 1.54 to 3.69; N = 2273; I² = 41%), in favour of incentives.

AUTHORS' CONCLUSIONS

Overall there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The effectiveness of incentives appears to be sustained even when the last follow-up occurs after the withdrawal of incentives. There is also moderate-certainty evidence, limited by some concerns about risks of bias, that incentive schemes conducted among pregnant smokers improve smoking cessation rates, both at the end of pregnancy and post-partum. Current and future research might explore more precisely differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations.

Efficacy of mindfulness-based addiction treatment (MBAT) for smoking cessation and lapse recovery: A randomized clinical trial

OBJECTIVE

To compare the efficacy of Mindfulness-Based Addiction Treatment (MBAT) to a Cognitive Behavioral Treatment (CBT) that matched MBAT on treatment contact time, and a Usual Care (UC) condition that comprised brief individual counseling.

METHOD

Participants (N = 412) were 48.2% African American, 41.5% non-Latino White, 5.4% Latino, and 4.9% other, and 57.6% reported a total annual household income < $30,000. The majority of participants were female (54.9%). Mean cigarettes per day was 19.9 (SD = 10.1). Following the baseline visit, participants were randomized to UC (n = 103), CBT (n = 155), or MBAT (n = 154). All participants were given self-help materials and nicotine patch therapy. CBT and MBAT groups received 8 2-hr in-person group counseling sessions. UC participants received 4 brief individual counseling sessions. Biochemically verified smoking abstinence was assessed 4 and 26 weeks after the quit date.

RESULTS

Logistic random effects model analyses over time indicated no overall significant treatment effects (completers only: F(2, 236) = 0.29, p = .749; intent-to-treat: F(2, 401) = 0.9, p = .407). Among participants classified as smoking at the last treatment session, analyses examining the recovery of abstinence revealed a significant overall treatment effect, F(2, 103) = 4.41, p = .015 (MBAT vs. CBT: OR = 4.94, 95% CI: 1.47 to 16.59, p = .010, Effect Size = .88; MBAT vs. UC: OR = 4.18, 95% CI: 1.04 to 16.75, p = .043, Effect Size = .79).

CONCLUSION

Although there were no overall significant effects of treatment on abstinence, MBAT may be more effective than CBT or UC in promoting recovery from lapses. (PsycINFO Database Record

Effects of bupropion sustained release on task-related EEG alpha activity in smokers: Individual differences in drug response

The mechanisms underlying bupropion's efficacy as an antidepressant and a smoking cessation aid are far from being fully characterized. The present study is the first to examine the effects of bupropion on visuospatial task-related parietal EEG alpha power asymmetry-an asymmetry that has previously been found to be associated with severity of depressive symptoms (i.e., the more depressive symptoms, the greater alpha power in the right vs. left parietal area [Henriques & Davidson, 1997; Rabe, Debener, Brocke, & Beauducel, 2005]). Participants, all of whom were smokers and none of whom were clinically depressed, were randomly assigned to the Placebo group (n = 79) or Bupropion group (n = 31) in a double-blind study. EEG during the performance of the visuospatial task was collected before and after 14 days on placebo or bupropion sustained-release capsules. Relative to the Placebo group, the Bupropion group (especially, the Bupropion subgroup who had a positive right versus left parietal alpha power asymmetry at pretreatment) had a reduction in the parietal alpha asymmetry (driven largely by a decrease in right parietal alpha power). These findings support the hypothesis that bupropion can induce changes in parietal EEG asymmetry that have been shown in previous literature to be associated with a reduction in depressive states and traits. (PsycINFO Database Record

Guided Imagery for Smoking Cessation in Adults: A Randomized Pilot Trial

This pilot study describes a randomized controlled trial of an audio CD—based interactive guided imagery program for smoking cessation for adults versus a wait-listed control. Feasibility, process measures, and biochemically validated abstinence were assessed at end of treatment (6 weeks) and 12 weeks, as well as at 52 weeks for intervention participants. Fifty-nine percent of intervention participants attended four of six guided imagery sessions, and 94% found the technique helpful for smoking cessation. Intervention participants had greater readiness to quit (Readiness to Quit Ladder, 8.3 vs. 7.2, p < .05) and lower state anxiety (Spielberger Index, 32 vs. 38, p < .05) at end of treatment than the control group. Abstinence rates in the intervention versus control groups were 36% versus 18% ( p = .43) at 6 weeks and 30% versus 12% ( p = .40) at 12 weeks, respectively. At 1 year, 24% of intervention participants remained abstinent. A guided imagery program for smoking cessation was feasible, perceived to be helpful, improved intermediate measures, and resulted in a trend toward smoking cessation.

Anhedonia and the relative reward value of drug and nondrug reinforcers in cigarette smokers

Anhedonia-a psychopathologic trait indicative of diminished interest, pleasure, and enjoyment-has been linked to use of and addiction to several substances, including tobacco. We hypothesized that anhedonic drug users develop an imbalance in the relative reward value of drug versus nondrug reinforcers, which could maintain drug use behavior. To test this hypothesis, we examined whether anhedonia predicted the tendency to choose an immediate drug reward (i.e., smoking) over a less immediate nondrug reward (i.e., money) in a laboratory study of non-treatment-seeking adult cigarette smokers. Participants (N = 275, ≥10 cigarettes/day) attended a baseline visit that involved anhedonia assessment followed by 2 counterbalanced experimental visits: (a) after 16-hr smoking abstinence and (b) nonabstinent. At both experimental visits, participants completed self-report measures of mood state followed by a behavioral smoking task, which measured 2 aspects of the relative reward value of smoking versus money: (1) latency to initiate smoking when delaying smoking was monetarily rewarded and (2) willingness to purchase individual cigarettes. Results indicated that higher anhedonia predicted quicker smoking initiation and more cigarettes purchased. These relations were partially mediated by low positive and high negative mood states assessed immediately prior to the smoking task. Abstinence amplified the extent to which anhedonia predicted cigarette consumption among those who responded to the abstinence manipulation, but not the entire sample. Anhedonia may bias motivation toward smoking over alternative reinforcers, perhaps by giving rise to poor acute mood states. An imbalance in the reward value assigned to drug versus nondrug reinforcers may link anhedonia-related psychopathology to drug use.

Incentives for smoking cessation

BACKGROUND

Material or financial incentives are widely used in an attempt to precipitate or reinforce behaviour change, including smoking cessation. They operate in workplaces, in clinics and hospitals, and to a lesser extent within community programmes. In this third update of our review we now include trials conducted in pregnant women, to reflect the increasing activity and resources now targeting this high-risk group of smokers.

OBJECTIVES

To determine whether incentives and contingency management programmes lead to higher long-term quit rates.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. The most recent searches were in December 2014, although we also include two trials published in 2015.

SELECTION CRITERIA

We considered randomised controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. We include studies in a mixed-population setting (e.g. community-, work-, institution-based), and also, for this update, trials in pregnant smokers.

DATA COLLECTION AND ANALYSIS

One author (KC) extracted data and a second (JH-B) checked them. We contacted study authors for additional data where necessary. The main outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up, and at least six months from the start of the intervention. In the trials of pregnant smokers abstinence was measured at the longest follow-up, and at least to the end of the pregnancy.

MAIN RESULTS

Twenty-one mixed-population studies met our inclusion criteria, covering more than 8400 participants. Ten studies were set in clinics or health centres, one in Thai villages served by community health workers, two in academic institutions, and the rest in worksites. All but six of the trials were run in the USA. The incentives included lottery tickets or prize draws, cash payments, vouchers for goods and groceries, and in six trials the recovery of money deposited by those taking part. The odds ratio (OR) for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.42 (95% confidence interval (CI) 1.19 to 1.69; 17 trials, [20 comparisons], 7715 participants). Only three studies demonstrated significantly higher quit rates for the incentives group than for the control group at or beyond the six-month assessment: One five-arm USA trial compared rewards- and deposit-based interventions at individual and group level, with incentives available up to USD 800 per quitter, and demonstrated a quit rate in the rewards groups of 8.1% at 12 months, compared with 4.7% in the deposits groups. A direct comparison between the rewards-based and the deposit-based groups found a benefit for the rewards arms, with an OR at 12 months of 1.76 (95% CI 1.22 to 2.53; 2070 participants). Although more people in this trial accepted the rewards programmes than the deposit programmes, the proportion of quitters in each group favoured the deposit-refund programme. Another USA study rewarded both participation and quitting up to USD 750, and achieved sustained quit rates of 9.4% in the incentives group compared with 3.6% for the controls. A deposit-refund trial in Thailand also achieved significantly higher quit rates in the intervention group (44.2%) compared with the control group (18.8%), but uptake was relatively low, at 10.5%. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. We rated the overall quality of the older studies as low, but with later trials (post-2000) more likely to meet current standards of methodology and reporting.Eight of nine trials with usable data in pregnant smokers (seven conducted in the USA and one in the UK) delivered an adjusted OR at longest follow-up (up to 24 weeks post-partum) of 3.60 (95% CI 2.39 to 5.43; 1295 participants, moderate-quality studies) in favour of incentives. Three of the trials demonstrated a clear benefit for contingent rewards; one delivered monthly vouchers to confirmed quitters and to their designated 'significant other supporter', achieving a quit rate in the intervention group of 21.4% at two months post-partum, compared with 5.9% among the controls. Another trial offered a scaled programme of rewards for the percentage of smoking reduction achieved over the course of the 12-week intervention, and achieved an intervention quit rate of 31% at six weeks post-partum, compared with no quitters in the control group. The largest (UK-based) trial provided intervention quitters with up to GBP 400-worth of vouchers, and achieved a quit rate of 15.4% at longest follow-up, compared to the control quit rate of 4%. Four trials confirmed that payments made to reward a successful quit attempt (i.e. contingent), compared to fixed payments for attending the antenatal appointment (non-contingent), resulted in higher quit rates. Front-loading of rewards to counteract early withdrawal symptoms made little difference to quit rates.

AUTHORS' CONCLUSIONS

Incentives appear to boost cessation rates while they are in place. The two trials recruiting from work sites that achieved sustained success rates beyond the reward schedule concentrated their resources into substantial cash payments for abstinence. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available, and within a relatively affluent and educated population. Deposit-refund trials can suffer from relatively low rates of uptake, but those who do sign up and contribute their own money may achieve higher quit rates than reward-only participants. Incentive schemes conducted among pregnant smokers improved the cessation rates, both at the end-of-pregnancy and post-partum assessments. Current and future research might continue to explore the scale, loading and longevity of possible cash or voucher reward schedules, within a variety of smoking populations.

Lack of GABAB receptors modifies behavioural and biochemical alterations induced by precipitated nicotine withdrawal

The nicotine (NIC) withdrawal syndrome is considered to be a major cause of the high relapse rate among individuals undergoing smoking cessation. The aim of the present study was to evaluate a possible role of GABAB receptors in NIC withdrawal, by comparing GABAB1 knockout mice and their wild-type littermates. We analysed the time course of the global withdrawal score, the anxiety-like effects, monoamine concentrations, the brain-derived neurotrophic factor (BDNF) expression, the corticosterone plasmatic levels and [(3)H]epibatidine binding sites during NIC withdrawal precipitated by mecamylamine, a nicotinic receptor antagonist (MEC). In NIC withdrawn wild-type mice, we observed a global withdrawal score, an anxiety-like effect in the elevated plus maze, a decrease of the striatal dopamine and 3,4-dihydroxyphenylacetic acid concentrations, an increase of corticosterone plasma levels, a reduction of BDNF expression in several brain areas and an increase of [(3)H]epibatidine binding sites in specific brain regions. Interestingly, the effects found in NIC withdrawn wild-type mice were absent in GABAB1 knockout mice, suggesting that GABAB1 subunit of the GABAB receptor is involved in the regulation of the behavioural and biochemical alterations induced by NIC withdrawal in mice. These results reveal an interaction between the GABAB receptors and the neurochemical systems through which NIC exerts its long-term effects.

Nicotine and non-nicotine smoking factors differentially modulate craving, withdrawal and cerebral blood flow as measured with arterial spin labeling

Smoking cessation results in withdrawal symptoms such as craving and negative mood that may contribute to lapse and relapse. Little is known regarding whether these symptoms are associated with the nicotine or non-nicotine components of cigarette smoke. Using arterial spin labeling, we measured resting-state cerebral blood flow (CBF) in 29 adult smokers across four conditions: (1) nicotine patch+denicotinized cigarette smoking, (2) nicotine patch+abstinence from smoking, (3) placebo patch+denicotinized cigarette smoking, and (4) placebo patch+abstinence from smoking. We found that changes in self-reported craving positively correlated with changes in CBF from the denicotinized cigarette smoking conditions to the abstinent conditions. These correlations were found in several regions throughout the brain. Self-reported craving also increased from the nicotine to the placebo conditions, but had a minimal relationship with changes in CBF. The results of this study suggest that the non-nicotine components of cigarette smoke significantly impact withdrawal symptoms and associated brain areas, independently of the effects of nicotine. As such, the effects of non-nicotine factors are important to consider in the design and development of smoking cessation interventions and tobacco regulation.

Posttraumatic stress symptoms and tobacco abstinence effects in a non-clinical sample: evaluating the mediating role of negative affect reduction smoking expectancies

The relation between posttraumatic stress symptoms and smoking is well documented but poorly understood. The present investigation sought to evaluate the impact of posttraumatic stress symptoms on subjective and behavioral tobacco abstinence effects both directly and indirectly through negative affect reduction smoking outcome expectancies. Participants included 275 (68.7% male; Mage =43.9, 10+ cig/day) adult non-treatment seeking smokers, who attended two counterbalanced laboratory sessions (16 h of smoking deprivation vs ad libitum smoking), during which they completed self-report measures of withdrawal symptoms and mood followed by a smoking lapse task in which they could earn money for delaying smoking and purchase cigarettes to smoke. Results supported a mediational pathway whereby higher baseline symptoms of posttraumatic stress predicted greater endorsement of expectancies that smoking will effectively reduce negative affect, which in turn predicted greater abstinence-provoked exacerbations in nicotine withdrawal symptoms and negative affect. Posttraumatic stress symptoms also predicted number of cigarettes purchased independent of negative affect reduction expectancies, but did not predict delaying smoking for money. Findings highlight tobacco abstinence effects as a putative mechanism underlying posttraumatic stress disorder (PTSD)-smoking comorbidity, indicate an important mediating role of beliefs for smoking-induced negative affect reduction, and shed light on integrated treatment approaches for these two conditions.

Adolescent brain maturation and smoking: what we know and where we're headed

Smoking is a leading cause of mortality and morbidity worldwide. Smoking initiation often occurs during adolescence. This paper reviews and synthesizes adolescent development and nicotine dependence literatures to provide an account of adolescent smoking from onset to compulsive use. We extend neurobiological models of adolescent risk-taking, that focus on the interplay between incentive processing and cognitive control brain systems, through incorporating psychosocial and contextual factors specific to smoking, to suggest that adolescents are more vulnerable than adults to cigarette use generally, but that individual differences exist placing some adolescents at increased risk for smoking. Upon smoking, adolescents are more likely to continue smoking due to the increased positive effects induced by nicotine during this period. Continued use during adolescence, may be best understood as reflecting drug-related changes to neural systems underlying incentive processing and cognitive control, resulting in decision-making that is biased towards continued smoking. Persistent changes following nicotine exposure that may underlie continued dependence are described. We highlight ways that interventions may benefit from a consideration of cognitive-neuroscience findings.

Nicotine withdrawal and stress-induced changes in pain sensitivity: a cross-sectional investigation between abstinent smokers and nonsmokers

Chronic smoking has been linked with alterations in endogenous pain regulation. These alterations may be pronounced when individuals quit smoking because nicotine withdrawal produces a variety of psychological and physiological symptoms. Smokers interested in quitting (n = 98) and nonsmokers (n = 37) completed a laboratory session including cold pressor test (CPT) and heat thermal pain. Smokers set a quit date and completed the session after 48 h of abstinence. Participants completed the pain assessments once after rest and once after stress. Cardiovascular and nicotine withdrawal measures were collected. Smokers showed blunted cardiovascular responses to stress relative to nonsmokers. Only nonsmokers had greater pain tolerance to CPT after stress than after rest. Lower systolic blood pressure was related to lower pain tolerance. These findings suggest that smoking withdrawal is associated with blunted stress response and increased pain sensitivity.

EPA Guidance on Tobacco Dependence and Strategies for Smoking Cessation in People with Mental Illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.

Coping Mediates the Association of Mindfulness with Psychological Stress, Affect, and Depression Among Smokers Preparing to Quit

It is not surprising that smoking abstinence rates are low given that smoking cessation is associated with increases in negative affect and stress that can persist for months. Mindfulness is one factor that has been broadly linked with enhanced emotional regulation. This study examined baseline associations of self-reported trait mindfulness with psychological stress, negative affect, positive affect, and depression among 158 smokers enrolled in a smoking cessation treatment trial. Several coping dimensions were evaluated as potential mediators of these associations. Results indicated that mindfulness was negatively associated with psychological stress, negative affect and depression, and positively associated with positive affect. Furthermore, the use of relaxation as a coping strategy independently mediated the association of mindfulness with psychological stress, positive affect, and depression. The robust and consistent pattern that emerged suggests that greater mindfulness may facilitate cessation and attenuate vulnerability to relapse among smokers preparing for cessation. Furthermore, relaxation appears to be a key mechanism underlying these associations. The ClinicalTrials.gov identifier is NCT00297479.

Changes in prevalence of depression and anxiety following smoking cessation: results from an international cohort study (ATTEMPT)

BACKGROUND

Smoking cessation improves physical health but it has been suggested that in vulnerable individuals it may worsen mental health. This study aimed to identify the short- and longer-term effects of stopping smoking on depression and anxiety in the general population and in those with a history of these disorders.

METHOD

Sociodemographic and smoking characteristics, and mental and physical health were assessed using established measures in the ATTEMPT cohort, an international longitudinal study of smokers (n = 3645). Smokers who had stopped for at least 3 months or less than 3 months at the 12-month follow-up were compared with current smokers (n = 1640).

RESULTS

At follow-up, 9.7% [95% confidence interval (CI) 8.3-11.2] of smokers had stopped for less than 3 months and 7.5% (95% CI 6.3-8.9) for at least 3 months. Compared with current smokers, prevalence of depression prescriptions obtained in the last 2 weeks was lower for those who had stopped for less than 3 months [odds ratio (OR) 0.37, 95% CI 0.14-0.96] or at least 3 months (OR 0.25, 95% CI 0.06-0.94) after adjusting for baseline prescription levels and confounding variables. Adjusted prevalence of recent depression symptoms was also lower for ex-smokers who had stopped for less than 3 months (OR 0.34, 95% CI 0.15-0.78) or at least 3 months (OR 0.24, 95% CI 0.09-0.67) than among continuing smokers. There was no change in anxiety measures in the general population or any increase in anxiety or depression symptoms in ex-smokers with a past history of these conditions.

CONCLUSIONS

Smoking cessation does not appear to be associated with an increase in anxiety or depression and may lead to a reduced incidence of depression.

Alcohol, nicotine, and iatrogenic withdrawals in the ICU

OBJECTIVES

The neurophysiology, risk factors, and screening tools associated with alcohol withdrawal syndrome in the ICU are reviewed. Alcohol withdrawal syndrome assessment and its treatment options are discussed. Description of nicotine withdrawal and related publications specific to the critically ill are also reviewed. A brief comment as to sedative and opiate withdrawal follows.

DATA AND SUMMARY

The role of currently published alcohol withdrawal syndrome pharmacologic strategies (benzodiazepines, ethanol, clomethiazole, antipsychotics, barbiturates, propofol, and dexmedetomidine) is detailed. Studies on nicotine withdrawal management in the ICU focus mainly on the safety (mortality) of nicotine replacement therapy. Study characteristics and methodological limitations are presented.

CONCLUSION

We recommend a pharmacologic regimen titrated to withdrawal symptoms in ICU patients with alcohol withdrawal syndrome. Benzodiazepines are a reasonable option; phenobarbital appears to confer some advantages in combination with benzodiazepines. Propofol and dexmedetomidine have not been rigorously tested in comparative studies of drug withdrawal treatment; their use as additional or alternative strategies for managing withdrawal syndromes in ICU patients should therefore be individualized to each patient. Insufficient data preclude recommendations as to nicotine replacement therapy and management of iatrogenic drug withdrawal in ICU patients.

Mindful attention reduces neural and self-reported cue-induced craving in smokers

An emerging body of research suggests that mindfulness-based interventions may be beneficial for smoking cessation and the treatment of other addictive disorders. One way that mindfulness may facilitate smoking cessation is through the reduction of craving to smoking cues. The present work considers whether mindful attention can reduce self-reported and neural markers of cue-induced craving in treatment seeking smokers. Forty-seven (n = 47) meditation-naïve treatment-seeking smokers (12-h abstinent from smoking) viewed and made ratings of smoking and neutral images while undergoing functional magnetic resonance imaging (fMRI). Participants were trained and instructed to view these images passively or with mindful attention. Results indicated that mindful attention reduced self-reported craving to smoking images, and reduced neural activity in a craving-related region of subgenual anterior cingulate cortex (sgACC). Moreover, a psychophysiological interaction analysis revealed that mindful attention reduced functional connectivity between sgACC and other craving-related regions compared to passively viewing smoking images, suggesting that mindfulness may decouple craving neurocircuitry when viewing smoking cues. These results provide an initial indication that mindful attention may describe a 'bottom-up' attention to one's present moment experience in ways that can help reduce subjective and neural reactivity to smoking cues in smokers.

YMCA commit to quit: randomized trial outcomes

BACKGROUND

Vigorous-intensity exercise has been shown to aid in smoking cessation, especially among women. In a previous trial, cognitive behavioral therapy (CBT) for smoking cessation plus regular vigorous aerobic exercise enhanced cessation rates, improved exercise capacity, and reduced weight gain compared to CBT plus equal contact time.

PURPOSE

This study examined the effectiveness of this program adapted for and implemented in the YMCAs.

DESIGN

An RCT comparing CBT + Exercise (Exercise) to CBT + Contact Control (Control).

SETTING/PARTICIPANTS

Apparently healthy female smokers were recruited to four local YMCAs.

INTERVENTION

YMCA staff members were trained to lead the manualized CBT smoking-cessation intervention and a standardized YMCA exercise program.

MAIN OUTCOME MEASURES

Seven-day point prevalence and continuous abstinence.

RESULTS

Participants (330 women, mean age=44 years) were randomized to the Exercise (n=166) or Control (n=164) group. Results revealed no differences in 7-day point prevalence (29.5% vs 29.9%) nor continuous abstinence (13.9% vs 14.0%) between the Exercise and Control groups, respectively, at end of treatment or at the 3-, 6-, and 12-month follow-up. An examination of the relationship between exercise dose and quit status at end of treatment revealed that over 12 weeks, the odds of being quit (7-day point prevalence) grew by 4.5% for each additional aerobic exercise session (OR=1.05, 95% CI=1.01, 1.08) and by 7.7% for each additional resistance training session (OR=1.08, 95% CI=1.02, 1.14). Analyses were conducted between August 19, 2010, and December 16, 2011.

CONCLUSIONS

No differences were seen between groups in smoking outcomes. The association between greater exercise participation and higher odds of quitting within the exercise condition suggests that the lack of between-group differences might be a result of poor compliance with the exercise program.

TRIAL REGISTRATION

This study is registered at clinicaltrials.govNCT01615380.

Smoking abstinence and depressive symptoms modulate the executive control system during emotional information processing

Smoking abstinence disrupts affective and cognitive processes. In this study, functional magnetic resonance imaging (fMRI) was used to investigate the effects of smoking abstinence on emotional information processing. Smokers (n = 17) and non-smokers (n = 18) underwent fMRI while performing an emotional distractor oddball task in which rare targets were presented following negative and neutral task-irrelevant distractors. Smokers completed two sessions: once following 24-hour abstinence and once while satiated. The abstinent versus satiated states were compared by evaluating responses to distractor images and to targets following each distractor valence within frontal executive and limbic brain regions. Regression analyses were done to investigate whether self-reported negative affect influences brain response to images and targets. Exploratory regression analyses examined relations between baseline depressive symptoms and smoking state on brain function. Smoking state affected response to target detection in the right inferior frontal gyrus (IFG). During satiety, activation was greater in response to targets following negative versus neutral distractors; following abstinence, the reverse was observed. Withdrawal-related negative affect was associated with right insula activation to negative images. Finally, depression symptoms were associated with abstinence-induced hypoactive response to negative emotional distractors and task-relevant targets following negative distractors in frontal brain regions. Neural processes related to novelty detection/attention in the right IFG may be disrupted by smoking abstinence and negative stimuli. Reactivity to emotional stimuli and the interfering effects on cognition are moderated by the magnitude of smoking state-dependent negative affect and baseline depressive symptoms.

Varenicline prevents affective and cognitive exacerbation during smoking abstinence in male patients with schizophrenia

To explore the effects of varenicline on the psychopathology and cognition of chronic inpatients with schizophrenia, we conducted a non-randomized control group time series investigation between March 2009 and April 2010. In a mandatory smoking cessation intervention, 41 male inpatient smokers were scheduled to undergo either a 5-week varenicline treatment (varenicline group) or the use of no drugs (non-treatment group). Depression (HAM-D), anxiety (HAM-A), and psychosis (PANSS) were evaluated at baseline, and at the 2nd, 4th, 8th and 12th week after abstinence; four neuropsychological tests, including Digit Span Forward and Backward (DSF and DSB), and Trail Making Test-A and -B, were evaluated at baseline and at the 4th, 8th and 12th week. .Thirty patients completed the study. Among 15 patients in the non-treatment group, the HAM-D, HAM-A, DSF, and DSB scores were exacerbated during the 2-8 weeks of abstinence, but there were no changes in psychotic symptoms and the other two neuropsychological tests. Compared with the non-treatment group, varenicline users experienced less impairment in HAM-D and HAM-A scores at the 2nd and 4th weeks, and in DSF tasks at the 4th week after abstinence. In conclusions, varenicline can attenuate abstinence-induced adverse outcomes and appears to be well-tolerated in smokers with schizophrenia.

Mechanistic insights into nicotine withdrawal

Smoking is responsible for over 400,000 premature deaths in the United States every year, making it the leading cause of preventable death. In addition, smoking-related illness leads to billions of dollars in healthcare expenditures and lost productivity annually. The public is increasingly aware that successfully abstaining from smoking at any age can add years to one's life and reduce many of the harmful effects of smoking. Although the majority of smokers desire to quit, only a small fraction of attempts to quit are actually successful. The symptoms associated with nicotine withdrawal are a primary deterrent to cessation and they need to be quelled to avoid early relapse. This review will focus on the neuroadaptations caused by chronic nicotine exposure and discuss how those changes lead to a withdrawal syndrome upon smoking cessation. Besides examining how nicotine usurps the endogenous reward system, we will discuss how the habenula is part of a circuit that plays a critical role in the aversive effects of high nicotine doses and nicotine withdrawal. We will also provide an updated summary of the role of various nicotinic receptor subtypes in the mechanisms of withdrawal. This growing knowledge provides mechanistic insights into current and future smoking cessation therapies.

Yoga as a complementary treatment for smoking cessation in women

BACKGROUND

Tobacco smoking remains the leading preventable cause of death among American women. Aerobic exercise has shown promise as an aid to smoking cessation because it improves affect and reduces nicotine withdrawal symptoms. Studies outside the realm of smoking cessation have shown that yoga practice also reduces perceived stress and negative affect.

METHODS

This pilot study examines the feasibility and initial efficacy of yoga as a complementary therapy for smoking cessation. Fifty-five women were given 8-week group-based cognitive behavioral therapy for smoking cessation and were randomized to a twice-weekly program of Vinyasa yoga or a general health and wellness program (contact control). The primary outcome measure was 7-day point prevalence abstinence at the end of treatment validated by saliva cotinine testing. Longitudinal analyses were also conducted to examine the effect of intervention on smoking cessation at 3- and 6-month follow-up. We examined the effects of the intervention on potential mediating variables (e.g., confidence in quitting smoking, self-efficacy), as well as measures of depressive symptoms, anxiety, and perceived health (SF-36).

RESULTS

At end of treatment, women in the yoga group had a greater 7-day point-prevalence abstinence rate than controls (odds ratio [OR], 4.56; 95% CI, 1.1-18.6). Abstinence remained higher among yoga participants through the six month assessment (OR, 1.54; 95% CI, 0.34-6.92), although differences were no longer statistically significant. Women participating in the yoga program also showed reduced anxiety and improvements in perceived health and well-being when compared with controls.

CONCLUSIONS

Yoga may be an efficacious complementary therapy for smoking cessation among women.

Markov model of smoking cessation

Survival functions from smoking cessation interventions are described by a three-state Markov model. On quitting, smokers transit through a state of withdrawal characterized by a high rate of relapse, and then into a more secure state of long-term abstinence. The Markov model embodies the dynamic nature of the cessation/relapse process; it permits stronger inference to long-term abstinence rates, provides measures of treatment efficacy, describes the outcomes of new quit attempts, and suggests mechanisms for the survival process.

Effects of nicotine on electroencephalography and affect in adolescent females with major depressive disorder: a pilot study

BACKGROUND

Given that smoking is typically initiated during adolescence, and that this period in brain development seems to be uniquely sensitive to nicotine, depressed youth may be most susceptible to the neuromodulatory and mood-altering effects of nicotine. Electroencephalographic (EEG) studies suggest that individuals with major depressive disorder (MDD) exhibit left frontal lobe hypoactivation (indexed by increased EEG alpha), a region implicated in positive affect regulation, as well as right parietal hypoactivation. Smoking/nicotine abstinence has been associated with increased left frontal and right parietal alpha activity (reduced activation), which has been correlated with increased depression ratings; nicotine administration seems to normalize this depression-associated asymmetry.

OBJECTIVES

This pilot study investigated whether acute nicotine administration in adolescent female smokers with MDD would alter resting EEG activity and affect.

METHODS

Subjective mood ratings and EEG recordings were acquired before and 2 hours after administering a transdermal placebo or nicotine (21 mg) patch to 8 adolescent female smokers with MDD.

RESULTS

Nicotine induced a modest increase in alpha1 amplitude in the right hemisphere and simultaneously decreased left-favoring alpha1 amplitude asymmetry. It also attenuated left alpha1 and alpha2 amplitude in the central region. Consistent with nicotine's stimulatory action, nicotine decreased theta amplitude in the right parietal region. No accompanying mood alterations were found, although smoking withdrawal and craving as well as physical symptom scores were reduced with nicotine.

CONCLUSIONS

The results of this pilot study, the first to examine the electrocortical effects of nicotine in depressed adolescents, indicate that nicotine modulates EEG asymmetry measures, laying the stage for further research regarding the role of nicotine on affective neurocircuitry in this population.

Competitions and incentives for smoking cessation

BACKGROUND

Background Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Public health initiatives in the UK are currently planning to deploy incentive schemes to change unhealthy behaviours. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in November 2010.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author (KC) and checked by the second (RP). We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Nineteen studies met our inclusion criteria, covering >4500 participants. Only one study, the largest in our review and covering 878 smokers, demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. This trial referred its participants to local smoking cessation services, and offered substantial cash payments (up to US$750) for prolonged abstinence. In the remaining trials, there was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that contingent rewards enhanced success rates over fixed payment schedules. There is some evidence that recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis was not appropriate to this review, since the efficacy of most of the interventions was not demonstrated.

AUTHORS' CONCLUSIONS

With the exception of one recent trial, incentives and competitions have not been shown to enhance long-term cessation rates. Early success tended to dissipate when the rewards were no longer offered. Rewarding participation and compliance in contests and cessation programmes may have potential to deliver higher absolute numbers of quitters. The one trial that achieved sustained success rates beyond the reward schedule concentrated its resources into substantial cash payments for abstinence rather than into running its own smoking cessation programme. Such an approach may only be feasible where independently-funded smoking cessation programmes are already available. Future research might explore the scale and longevity of possible cash reward schedules, within a variety of smoking populations.

Nicotine withdrawal symptoms in adolescent and adult twins

We examined the variation and heritability of DSM-IV nicotine withdrawal (NW) in adult and adolescent male and female twin cigarette smokers (who reported smoking 100 or more cigarettes lifetime). Telephone diagnostic interviews were completed with 3,112 Australian adult male and female smokers (53% women; age: 24-36) and 702 Missouri adolescent male and female smokers (59% girls; age: 15-21). No gender or cohort differences emerged in rates of meeting criteria for NW (44%). Latent class analyses found that NW symptoms were best conceptualized as a severity continuum (three levels in adults and two levels in adolescents). Across all groups, increasing NW severity was associated with difficulty quitting, impairment following cessation, heavy smoking, depression, anxiety, conduct disorder and problems with alcohol use. NW was also associated with seeking smoking cessation treatment and with smoking persistence in adults. The latent class structure of NW was equally heritable across adult and adolescent smokers with additive genetic influences accounting for 49% of the variance and the remaining 51% of variance accounted for by unique environmental influences. Overall, findings suggest remarkable similarity in the pattern and heritability of NW across adult and adolescent smokers, and highlight the important role of NW in psychiatric comorbidity and the process of smoking cessation across both age groups.

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

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

Subjective well-being, personality, demographic variables, and American state differences in smoking prevalence

INTRODUCTION

The present study was conducted to determine relations between smoking prevalence, subjective well-being, and the Big Five personality variables at the American state level.

METHOD

State smoking prevalence was based on the responses of more than 350,000 adults interviewed in the Behavioral Risk Factor Surveillance System in 2008. Subjective well-being was based on the state-aggregated responses of 353,039 adults to the Gallup-Healthways Well-Being Index phone interviews during 2008. Big Five variables were based on the state-aggregated responses of 619,397 persons to an Internet survey between 1999 and 2005, which included the 44-item Big Five Inventory.

RESULTS

Well-being and smoking prevalence were negatively correlated and remained so when state Big Five, socioeconomic status (SES), White population percent, urban population percent, and median age were controlled in a partial correlation. Hierarchical and stepwise multiple regressions showed (a) that SES and neuroticism were the prime predictors of well-being, (b) that well-being was the prime predictor of smoking prevalence, and (c) that openness to experience was the sole personality or demographic variable to account for differences in smoking prevalence when well-being was controlled, and it explained very little of the remaining variance.

DISCUSSION

Applied implications for state-tailored attempts to reduce smoking are briefly discussed, and suggestions for future research directions are put forward.

Single versus recurrent depression history: differentiating risk factors among current US smokers

INTRODUCTION

The strong relationship between persistent tobacco use and Major Depressive Disorder (MDD) has motivated clinical trials of specialized treatments targeting smokers with a history of MDD. Meta-analyses suggest positive responses to specialized treatments have been observed consistently among smokers with history of recurrent rather than a single episode of MDD. Approximately 15% of current US smokers have a history of recurrent MDD. Little is known about the risk factors that contribute to persistent smoking and differentiate these at-risk smokers, US.

METHODS

The National Comorbidity Survey - Replication (NCS-R) included a survey of 1560 smokers participants aged 18 and older in the United States. Lifetime history of MDD was categorized according to chronicity: no history (No MDD), single episode (MDD-S) and recurrent depression (MDD-R). The relationship between the chronicity of MDD, smoking characteristics, cessation history, nicotine dependence, comorbidity with psychiatric disorders, and current functional impairments were examined.

RESULTS

MDD-R smokers reported fewer lifetime cessation efforts, smoked more cigarettes, had higher levels of nicotine dependence, had higher rates of comorbid psychiatric disorders and greater functional impairment than smokers with No MDD. MDD-S smokers were not consistently distinguished from No MDD smokers on cessation attempts, level of daily smoking, nicotine dependence or functional impairment indices.

CONCLUSIONS

The study highlights the importance of chronicity when characterizing depression-related risk of persistent smoking behavior. Although, clinical trials suggest MDD-R smokers specifically benefit from specialized behavioral treatments, these services are not widely available and more efforts are needed to engage MDD-R smokers in efficacious treatments.

Yoga as a complementary treatment for smoking cessation: rationale, study design and participant characteristics of the Quitting-in-Balance study

Background

Tobacco smoking remains the leading preventable cause of death among American women. Exercise has shown promise as an aid to smoking cessation because it reduces weight gain and weight concerns, improves affect, and reduces nicotine withdrawal symptoms and cigarette craving. Studies have shown that the practice of yoga improves weight control, and reduces perceived stress and negative affect. Yoga practice also includes regulation of breathing and focused attention, both of which may enhance stress reduction and improve mood and well-being and may improve cessation outcomes.

Methods/Design

This pilot efficacy study is designed to examine the rates of cessation among women randomized to either a novel, 8-week Yoga plus Cognitive Behavioral Therapy (CBT) smoking cessation intervention versus a Wellness program plus the same CBT smoking cessation intervention. Outcome measures include 7-day point prevalence abstinence at end of treatment, 3 and 6 months follow up and potential mediating variables (e.g., confidence in quitting smoking, self-efficacy). Other assessments include measures of mindfulness, spirituality, depressive symptoms, anxiety and perceived health (SF-36).

Discussion

Innovative treatments are needed that address barriers to successful smoking cessation among men and women. The design chosen for this study will allow us to explore potential mediators of intervention efficacy so that we may better understand the mechanism(s) by which yoga may act as an effective complementary treatment for smoking cessation. If shown to be effective, yoga can offer an alternative to traditional exercise for reducing negative symptoms that often accompany smoking cessation and predict relapse to smoking among recent quitters.

Trial Registration

ClinicalTrials NCT00492310

GABAA-benzodiazepine receptor availability in smokers and nonsmokers: relationship to subsyndromal anxiety and depression

Many smokers experience subsyndromal anxiety symptoms while smoking and during acute abstinence, which may contribute to relapse. We hypothesized that cortical gamma aminobutyric acid(A)-benzodiazepine receptor (GABA(A)-BZR) availability in smokers and nonsmokers might be related to the expression of subsyndromal anxiety, depressive, and pain symptoms. Cortical GABA(A)-BZRs were imaged in 15 smokers (8 men and 7 women), and 15 healthy age and sex-matched nonsmokers, and 4 abstinent tobacco smokers (3 men; 1 woman) using [(123)I]iomazenil and single photon emission computed tomography (SPECT). Anxiety and depressive symptoms were measured using the Spielberger's State-Trait Anxiety Index (STAI) and the Center for Epidemiology Scale for Depressive Symptoms (CES-D). The cold pressor task was administered to assess pain tolerance and sensitivity. The relationship between cortical GABA(A)-BZR availability, smoking status, and subsyndromal depression and anxiety symptoms, as well as pain tolerance and sensitivity, were evaluated. Surprisingly, there were no statistically significant differences in overall GABA(A)-BZR availability between smokers and nonsmokers or between active and abstinent smokers; however, cortical GABA(A)-BZR availability negatively correlated with subsyndromal state anxiety symptoms in nonsmokers but not in smokers. In nonsmokers, the correlation was seen across many brain areas with state anxiety [parietal (r = -0.47, P = 0.03), frontal (r = -0.46, P = 0.03), anterior cingulate (r = -0.47, P = 0.04), temporal (r = -0.47, P = 0.03), occipital (r = -0.43, P = 0.05) cortices, and cerebellum (r = -0.46, P = 0.04)], trait anxiety [parietal (r = -0.72, P = 0.02), frontal (r = -0.72, P = 0.02), and occipital (r = -0.65, P = 0.04) cortices] and depressive symptoms [parietal (r = -0.68; P = 0.02), frontal (r = -0.65; P = 0.03), anterior cingulate (r = -0.61; P = 0.04), and temporal (r = -0.66; P = 0.02) cortices]. The finding that a similar relationship between GABA(A)-BZR availability and anxiety symptoms was not observed in smokers suggests that there is a difference in GABA(A)-BZR function, but not number, in smokers. Thus, while subsyndromal anxiety and depressive symptoms in nonsmokers may be determined in part by GABA(A)-BZR availability, smoking disrupts this relationship. Aberrant regulation of GABA(A)-BZR function in vulnerable smokers may explain why some smokers experience subsyndromal anxiety and depression.

Hostility, cigarette smoking, and responses to a lab-based social stressor

High-trait hostility is associated with persistent cigarette smoking. To better understand mechanisms that may account for this association, we examined the effects of acute smoking abstinence and delayed versus immediate smoking reinstatement on responses to a social stressor among 48 low hostile (LH) and 48 high hostile (HH) smokers. Participants completed two laboratory sessions, one before which they had smoked ad lib and one before which they had abstained for the prior 12 hr. During each session, participants completed a stressful speaking task and then smoked immediately after the stressor or after a 15-min delay. The effect of immediate versus delayed smoking reinstatement on recovery in negative mood was significantly moderated by hostility. When reinstatement was delayed, HH participants showed significant increases in negative mood over time, whereas LH participants showed little change. When reinstatement was immediate, HH and LH smokers showed similar significant decreases in negative mood. Smoking abstinence did not moderate hostility effects. Cigarette smoking may prevent continuing increases in negative mood after social stress in HH smokers, which may partially explain their low rates of quitting.

Mechanisms underlying the comorbidity of tobacco use in mental health and addictive disorders

We discuss potential explanations for the high prevalence of tobacco use and tobacco dependence (TD) in people with mental health and addictive (MHA) disorders. The biopsychosocial basis for this comorbidity is presented, integrating evidence from epidemiologic and clinical studies. We also review evidence that suggests a shared vulnerability related to biological, genetic, and environmental factors may be the most parsimonious mechanism to explain the association between TD and MHA disorders. Finally, we review the examples of various MHA disorders that are associated with TD, and suggest avenues for new investigation that could aid in the development of rationale and more effective treatments for tobacco and MHA disorder comorbidities.

Patterns of change in withdrawal symptoms, desire to smoke, reward motivation and response inhibition across 3 months of smoking abstinence

AIMS

We have demonstrated previously that acute smoking abstinence is associated with lowered reward motivation and impaired response inhibition. This prospective study explores whether these impairments, along with withdrawal-related symptoms, recover over 3 months of sustained abstinence.

DESIGN

Participants completed a 12-hour abstinent baseline assessment and were then allocated randomly to quit unaided or continue smoking. All were re-tested after 7 days, 1 month and 3 months. Successful quitters' scores were compared with those of continuing smokers, who were tested after ad libitum smoking.

SETTING

Goldsmiths, University of London.

PARTICIPANTS

A total of 33 smokers who maintained abstinence to 3 months, and 31 continuing smokers.

MEASUREMENTS

Indices demonstrated previously in this cohort of smokers to be sensitive to the effect of nicotine versus acute abstinence: reward motivation [Snaith-Hamilton pleasure scale (SHAPS), Card Arranging Reward Responsivity Objective Test (CARROT), Stroop], tasks of response inhibition [anti-saccade task; Continuous Performance Task (CPT)], clinical indices of mood [Hospital Anxiety and Depression Scale (HADS)], withdrawal symptoms [Mood and Physical Symptoms Scale (MPSS)] and desire to smoke.

FINDINGS

SHAPS anhedonia and reward responsivity (CARROT) showed significant improvement and plateaued after a month of abstinence, not differing from the scores of continuing smokers tested in a satiated state. Mood, other withdrawal symptoms and desire to smoke all declined from acute abstinence to 1 month of cessation and were equivalent to, or lower than, the levels reported by continuing, satiated smokers. Neither group showed a change in CPT errors over time while continuing smokers, but not abstainers, showed improved accuracy on the anti-saccade task at 3 months.

CONCLUSION

Appetitive processes and related affective states appear to improve in smokers who remain nicotine-free for 3 months, whereas response inhibition does not. Although in need of replication, the results suggest tentatively that poor inhibitory control may constitute a long-term risk factor for relapse and could be a target for intervention.

24-h smoking abstinence potentiates fMRI-BOLD activation to smoking cues in cerebral cortex and dorsal striatum

RATIONALE

Exposure to smoking-related cues can trigger relapse in smokers attempting to maintain abstinence.

OBJECTIVES

In the present study, we evaluated the effect of 24-h smoking abstinence on brain responses to smoking-related cues using functional magnetic resonance imaging (fMRI).

MATERIALS AND METHODS

Eighteen adult smokers underwent fMRI scanning following smoking as usual (satiated condition) and following 24-h abstinence (abstinent condition). During scanning, they viewed blocks of photographic smoking and control cues.

RESULTS

Following abstinence, greater activation was found in response to smoking cues compared to control cues in parietal (BA 7/31), frontal (BA 8/9), occipital (BA 19), and central (BA 4) cortical regions and in dorsal striatum (putamen) and thalamus. In contrast, no smoking cue greater than control cue activations were observed following smoking as usual. Direct comparisons between conditions (satiated vs. abstinent) showed greater brain reactivity in response to smoking cues following abstinence. In addition, positive correlations between pre-scan craving in the abstinent condition and smoking cue activation were observed in right dorsomedial prefrontal cortex (dmPFC) including superior frontal gyrus (BA 6/10), anterior cingulate gyrus (BA 32), and supplementary motor area (BA 6).

CONCLUSIONS

The present findings indicate that smoking abstinence significantly potentiates neural responses to smoking-related cues in brain regions subserving visual sensory processing, attention, and action planning. Moreover, greater abstinence-induced craving was significantly correlated with increased smoking cue activation in dmPFC areas involved in action planning and decision making. These findings suggest that drug abstinence can increase the salience of conditioned cues, which is consistent with incentive-motivation models of addiction.

Influence of Neuronal Nicotinic Receptors over Nicotine Addiction and Withdrawal

Cigarette smoking represents an enormous, global public health threat. Nearly five million premature deaths during a single year are attributable to smoking. Despite the resounding message of risks associated with smoking and numerous public health initiatives, cigarette smoking remains the most common preventable cause of disease in the United States. Fortunately, even in an adult smoker, smoking cessation can reverse many of the potential harmful effects. The symptoms associated with nicotine withdrawal represent the major obstacle to smoking cessation. This minireview examines the roles of various nicotinic receptors in the mechanisms of nicotine dependence, discusses the potential role of the habenula-interpeduncular nucleus axis in nicotine withdrawal, and highlights nicotinic receptors containing the β4 subunit as a potential pharmacological target for smoking cessation strategies.

Effects of nicotine and depressive traits on affective priming of lateralized emotional word identification

Based on evidence suggesting that depressive traits, emotional information processing, and the effects of nicotine may be mediated by lateralized brain mechanisms, analyses assessed the influence of depressive traits and nicotine patch on emotional priming of lateralized emotional word identification in 61 habitual smokers. Consistent with hypotheses, nicotine as compared to placebo patch enhanced right visual field (RVF) emotional word identification while decreasing performance of emotional word identification in the left visual field (LVF). Nicotine also enhanced positive affect and decreased negative affect. Consistent with the Heller model of depression, scoring high in depressive traits was associated with a general decrease in LVF emotional word identification. Additionally, this general LVF deficit was especially pronounced for positive word identification in individuals scoring high in trait depression. Positive primes facilitated positive target identification in the RVF and negative primes facilitated negative target identification in the LVF. Thus, nicotine promoted a LVF word-identification deficit similar to that observed in those with depressive traits. However, nicotine also enhanced RVF processing and reduced negative affect, whereas it enhanced positive affect.

Competitions and incentives for smoking cessation

BACKGROUND

Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review.

OBJECTIVES

To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in December 2007.

SELECTION CRITERIA

We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups.

MAIN RESULTS

Seventeen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

AUTHORS' CONCLUSIONS

Incentives and competitions have not been shown to enhance long-term cessation rates, with early success tending to dissipate when the rewards are no longer offered. Rewarding participation and compliance in contests and cessation programmes may have more potential to deliver higher absolute numbers of quitters.