Evaluation of cue reactivity in the natural environment of smokers using ecological momentary assessment

Virtual Reality Environmental Enrichment Effects on Craving for Cigarette in Smokers

Background: Preclinical studies suggested the exposure to environmental enrichment (EE) as an intervention able to prevent or reduce nicotine-taking and nicotine-seeking behaviors. Virtual reality (VR) may help to test the effects of EE in smokers in a reproducible and feasible manner. Materials and Methods: In the present study, 31 smokers (14 women) were divided into two groups: (1) exposure to a virtual EE (VR-EE) and (2) exposure to a virtual neutral environment (VR-NoEE). Cigarette craving was assessed as basal and evoked, at different timepoints during the session. Behavior activity during VR exposure, mood, and subjective measures were also collected. Results: EE exposure in VR significantly reduced craving scores from basal timepoint. This was not observed in the VR-NoEE group, which significantly increased craving compared with values at neutral scenario. When both groups were exposed to smoking-related VR scenario, the VR-EE group showed an increased craving compared with previous timepoint up to score values not different from those in the VR-NoEE group. A significant positive correlation between basal craving scores and interactive behavior with virtual smoking cues was observed in the VR-NoEE but not in the VR-EE group. Conclusion: These findings suggest that virtual EE might have an inhibitory effect in smokers on basal, but not on evoked cigarette craving. Noteworthily, the interactive activity correlation to craving scores in the VR-NoEE participants was not observed in the VR-EE group, adding further evidence that the enrichment simulation was nonetheless able to modify behavior in the smoking-related scenario.

Development and Initial Validation of a Momentary Cannabis Craving Scale Within a Homogeneous Sample of U.S. Emerging Adults

Given the popularity and ease of single-item craving assessments, we developed a multi-item measure and compared it to common single-item assessments in an ecological momentary assessment (EMA) context. Two weeks of EMA data were collected from 48 emerging adults (56.25% female, 85.42% White) who frequently used cannabis. Eight craving items were administered, and multilevel factor analyses were used to identify the best fitting model. The resulting scale's factors represented purposefulness/general desire and emotionality/negative affect craving. Convergent validity was examined using measures of craving, cannabis use disorder symptoms, frequency of use, cannabis cue reactivity, cannabis use, negative affect, and impulsivity. The scale factors were associated with cue-reactivity craving, negative affect, impulsivity, and subfactors of existing craving measures. For researchers interested in using a single item to capture craving, one item performed particularly well. However, the new scale may provide a more nuanced assessment of mechanisms underlying craving.

Sex differences in the relationship between cannabis use motives and cannabis craving in daily life in emerging adults

OBJECTIVE

Cannabis use motives and craving are associated with increased risk for cannabis-related problems and are ideal targets for prevention and early intervention. Patterns of motives and craving reactivity to cannabis cues differ by sex; however, few studies closely examine the relationship between motives and craving and how it may differ by valence (±) across men and women.

METHOD

The present study used Cue Reactivity Ecological Momentary Assessment to assess reward (+) and relief (-) craving four semirandom times per day for 2 weeks in a sample of 63 emerging adults (age 18-21; 54% cisgender women; 85.7% White) who frequently use cannabis (≥ 3 times per week). We assessed craving before and after exposure to brief neutral or cannabis image cues and examined within- and between-participant effects of cue type, motives, sex/gender, and their interactions, on postcue cannabis craving.

RESULTS

Regardless of cue type, women with high coping motives (-) reported less postcue relief (-) craving, and men with high enhancement motives (+) reported more postcue reward (+) craving. High enhancement motives (+), regardless of sex/gender, were associated with elevated relief (-) craving reactivity to cannabis cues, and women with high coping motives (-) reported elevated reward (+) craving reactivity to cannabis cues.

CONCLUSIONS

Sex/gender differences in the relationships between cannabis motives and craving reactivity indicate the value of a more targeted examination of valence (±) of craving experiences in addition to motives for use. Higher levels of precision may better inform interventions for emerging adults at risk for experiencing cannabis-related problems. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Distress tolerance and reactivity to negative affective cues in naturalistic environments of cannabis-using emerging adults

BACKGROUND

Distress tolerance (DT) has been implicated as an important factor in the experience of negative affect (NA) and cannabis craving. However, previous research is limited by its use of laboratory paradigms that may not replicate in naturalistic settings. The current study examined how DT influenced reactivity to NA cues in daily life in a sample of frequent (≥3 times per week) cannabis-using emerging adults (age 18-21).

METHODS

Using cue-reactivity ecological momentary assessment (CREMA), 63 (54 % female; 85.7 % white; M_age = 19.62) participants reported on their cannabis craving and affect (sadness, relaxation) four semi-random times per day for two weeks (56 possible CREMA sessions/participant). We assessed affect and cannabis craving before and after exposure to neutral and NA cues. Multilevel modeling was used to examine within- and between-participant effects of cues, DT, and sex, as well as within- and between-participant average pre-cue affect and craving, on post-cue affect and craving.

RESULTS

NA cues consistently predicted higher-than-normal post-cue sadness and lower relaxation, but not greater-than-normal post-cue craving. Cue type interacted with sex and DT to predict post-cue sadness, but not craving. Female participants and those reporting low DT reported higher sadness following NA cues compared to males and those with high DT, respectively.

CONCLUSIONS

Frequent cannabis-using emerging adults differed in affect, but not cannabis craving, reactivity to NA cues as a function of sex and DT. Our results were partially consistent with prior human laboratory and CREMA research finding greater reactivity to NA cues among females and individuals with low DT.

The impact of lofexidine on stress-related opioid craving and relapse: Design and methodology of a randomized clinical trial

Opioid Use Disorders (OUDs) and drug overdose deaths are increasing at alarmingly high rates in the United States. Stress and dysregulation in biologic stress response systems such as the hypothalamic-pituitary-adrenal axis and noradrenergic system appear to play an important role in the pathophysiology of substance use disorders and relapse to drug use, particularly for women. Alpha-2 adrenergic agonist medications effectively decrease noradrenergic activity and have demonstrated benefit in preventing relapse to substance use and decreasing stress-reactivity and craving in cocaine- and nicotine-dependent women, compared to men. Alpha-2 adrenergic agonists may help decrease stress reactivity in individuals with OUDs and prevent relapse to drug use, but gender differences have yet to be systematically explored. We describe the rationale, study design and methodology of a randomized, double-blind, placebo-controlled clinical trial examining gender differences in stress, craving and drug use among adult men and women with OUD taking methadone or buprenorphine and randomly assigned to an alpha-2 adrenergic agonist, lofexidine, compared to placebo. In addition, we describe methods for measuring daily stress, craving and drug use in participant's natural environment as well as participant's physiological (i.e., heart rate, cortisol) and psychological (i.e., stress, craving) response to laboratory social and drug cue stressors. Lastly, we detail methods adopted to sustain research activity while following guidelines for the COVID-19 pandemic. ClinicalTrials.gov Registration Number: NCT03718065.

Elements of Neuroanthropology

Neuroanthropology is the integration of neuroscience into anthropology and aims to understand “brains in the wild.” This interdisciplinary field examines patterns of human variation in field settings and provides empirical research that complements work done in clinical and laboratory settings. Neuroanthropology often uses ethnography in combination with theories and methods from cognitive science as a way to capture how culture, mind, and brain interact. This article describes nine elements that outline how to do neuroanthropology research: (1) integrating biology and culture through neuroscience and biocultural anthropology; (2) extending focus of anthropology on what people say and do to include what people process; (3) sizing culture appropriately, from broad patterns of culture to culture in small-scale settings; (4) understanding patterns of cultural variation, in particular how culture produces patterns of shared variation; (5) considering individuals in interaction with culture, with levels of analysis that can go from biology to social structures; (6) focusing on interactive elements that bring together biological and cultural processes; (7) conceptual triangulation, which draws on anthropology, psychology, and neuroscience in conjunction with field, clinic, and laboratory; (8) critical complementarity as a way to integrate the strengths of critical scholarship with interdisciplinary work; and (9) using methodological triangulation as a way to advance interdisciplinary research. These elements are illustrated through three case studies: research on US combat veterans and how they use Brazilian Jiu Jitsu as a way to manage the transition to becoming civilians, work on human-raptor interactions to understand how and why these interactions can prove beneficial for human handlers, and adapting cue reactivity research on addiction to a field-based approach to understand how people interact with cues in naturalistic settings.

Compliance With Mobile Ecological Momentary Assessment of Self-Reported Health-Related Behaviors and Psychological Constructs in Adults: Systematic Review and Meta-analysis

Background

Mobile ecological momentary assessment (mEMA) permits real-time capture of self-reported participant behaviors and perceptual experiences. Reporting of mEMA protocols and compliance has been identified as problematic within systematic reviews of children, youth, and specific clinical populations of adults.

Objective

This study aimed to describe the use of mEMA for self-reported behaviors and psychological constructs, mEMA protocol and compliance reporting, and associations between key components of mEMA protocols and compliance in studies of nonclinical and clinical samples of adults.

Methods

In total, 9 electronic databases were searched (2006-2016) for observational studies reporting compliance to mEMA for health-related data from adults (>18 years) in nonclinical and clinical settings. Screening and data extraction were undertaken by independent reviewers, with discrepancies resolved by consensus. Narrative synthesis described participants, mEMA target, protocol, and compliance. Random effects meta-analysis explored factors associated with cohort compliance (monitoring duration, daily prompt frequency or schedule, device type, training, incentives, and burden score). Random effects analysis of variance (P≤.05) assessed differences between nonclinical and clinical data sets.

Results

Of the 168 eligible studies, 97/105 (57.7%) reported compliance in unique data sets (nonclinical=64/105 [61%], clinical=41/105 [39%]). The most common self-reported mEMA target was affect (primary target: 31/105, 29.5% data sets; secondary target: 50/105, 47.6% data sets). The median duration of the mEMA protocol was 7 days (nonclinical=7, clinical=12). Most protocols used a single time-based (random or interval) prompt type (69/105, 65.7%); median prompt frequency was 5 per day. The median number of items per prompt was similar for nonclinical (8) and clinical data sets (10). More than half of the data sets reported mEMA training (84/105, 80%) and provision of participant incentives (66/105, 62.9%). Less than half of the data sets reported number of prompts delivered (22/105, 21%), answered (43/105, 41%), criterion for valid mEMA data (37/105, 35.2%), or response latency (38/105, 36.2%). Meta-analysis (nonclinical=41, clinical=27) estimated an overall compliance of 81.9% (95% CI 79.1-84.4), with no significant difference between nonclinical and clinical data sets or estimates before or after data exclusions. Compliance was associated with prompts per day and items per prompt for nonclinical data sets. Although widespread heterogeneity existed across analysis (I²>90%), no compelling relationship was identified between key features of mEMA protocols representing burden and mEMA compliance.

Conclusions

In this 10-year sample of studies using the mEMA of self-reported health-related behaviors and psychological constructs in adult nonclinical and clinical populations, mEMA was applied across contexts and health conditions and to collect a range of health-related data. There was inconsistent reporting of compliance and key features within protocols, which limited the ability to confidently identify components of mEMA schedules likely to have a specific impact on compliance.

Increases in endogenous progesterone attenuate smoking in a cohort of nontreatment seeking women: An exploratory prospective study

Despite advances in prevention and treatment, cigarette smoking remains a leading cause of preventable death in the United States. Although men and women are equally likely to attempt to quit smoking cigarettes, women are far less likely to achieve abstinence both during and following cessation treatment. Recent evidence suggests that ovarian hormone levels may play a role in successful abstinence attempts in women smokers. The primary goal of this exploratory prospective observational study was to estimate the association between within-participant levels of progesterone and estradiol with associated cigarettes smoked per day in adult women smokers (n = 104). The primary study outcome was self-reported cigarettes smoked per day (CPD) during a 2-week observational period collected using a daily smoking diary. Additionally, participants collected saliva daily, from which hormone levels (progesterone and estradiol) were derived. Higher within-participant progesterone levels were associated with a significant decrease in CPD (p = .008) whereas within-participant estradiol levels were unrelated to CPD (p = .25). Regression models indicated a single change in the trajectory of smoking behavior for both within-participant progesterone and estradiol. When progesterone values were below the change point, there was a significant inverse relationship between within-participant progesterone levels and smoking behavior (p = .025) whereas the relationship was attenuated for higher within-participant progesterone levels (p = .59). The effect of estradiol on smoking behavior was not significant when it was either below (p = .92) or above (p = .16) the change point. Higher within-participant levels of progesterone but not estradiol are associated with reduced CPD in nontreatment seeking women smokers.

Smokers "Context Reactivity" in Virtual Domestic Environments

INTRODUCTION

Although the effects of proximal smoking cues have been widely studied in smokers, little is known on the features associated with background spatial context effect, that is, "context reactivity." The aim of this study was to investigate context reactivity exhibited by smokers in virtual cue-free domestic scenarios.

METHODS

Sixty-nine participants divided in 2 cohorts (33 smokers and 36 non-smokers) were exposed to a virtual reality session with 4 domestic room scenarios presented in a balanced order: bedroom, bathroom, kitchen, and living room.

RESULTS

We showed that (i) it is possible to elicit smoking craving in smokers in virtual reality, and (ii) these effects are room dependent and (iii) associated with a lower sense of presence; furthermore, (iv) smokers reported higher craving scores for alcohol and food in a room-dependent fashion compared to non-smokers.

CONCLUSION

Our study provides an experimental paradigm for assessing context reactivity in smokers and suggests a potential use for the identification of non-pharmacological interventions as a co-adjuvant of smoking cessation treatment.

The influence of gender and oxytocin on stress reactivity, cigarette craving, and smoking in a randomized, placebo-controlled laboratory relapse paradigm

RATIONALE

Female cigarette smokers tend to show greater cessation failure compared with males. Variables that contribute to the maintenance of smoking, including stress and craving, may differentially impact male and female smokers. Novel pharmacotherapies, such as oxytocin, may attenuate stress reactivity and craving in smokers, but work in this area is limited.

OBJECTIVES

This study assessed the influence of gender and oxytocin on stress reactivity, craving, and smoking in a randomized, placebo-controlled laboratory relapse paradigm.

METHODS

Male and female adult cigarette smokers (ages 18-45) were enrolled (women oversampled 2:1) and completed a laboratory session, in which intranasal oxytocin or placebo was administered followed by a laboratory social stress task. The role of gender and oxytocin were assessed on measures of stress reactivity, cigarette craving, latency to smoke in a resistance task, subjective responses to smoking, and ad-libitum smoking.

RESULTS

Participants (N = 144) had a mean age of 31 were 63% female and 56% White. Following stress induction, female smokers evidenced greater subjective stress than males, though males demonstrated greater neuroendocrine reactivity and smoking intensity than females. No gender differences were demonstrated for craving. Oxytocin did not attenuate any aspect of stress reactivity, craving, smoking, or subjective responses to smoking compared with placebo.

CONCLUSIONS

Gender differences in stress reactivity were shown in the hypothesized direction, but oxytocin appeared to exert little impact on subjective or behavioral metrics. Results highlight the complex relationship between gender, stress, and smoking, as well as the implications for oxytocin as a potential pharmacotherapy for smoking cessation.

Sex Differences in Subjective and Behavioral Responses to Stressful and Smoking Cues Presented in the Natural Environment of Smokers

INTRODUCTION

Some evidence suggests that female smokers may show more context-dependent smoking and that males may show more stereotyped smoking (regardless of stress or cue exposure). The goal of this study was to characterize sex differences in response to stressful and smoking cues ecologically presented in daily life and variability in day-to-day smoking behavior.

METHODS

Adult smokers (N = 177) provided ratings of mood and cigarette craving before and after stress and smoking cues were presented four times daily for 14 days via a mobile device. Linear mixed models tested whether (1) female smokers exhibited greater reactivity to stressful cues than male smokers; (2) pre-cue negative affect increased reactivity to smoking cues more in female smokers than male smokers; (3) across both sexes, greater reactivity to stressful and smoking cues correlated with greater quantity of smoking within a day; and (4) female smokers exhibited greater variability in cigarettes per day (CPD) relative to males.

RESULTS

Relative to male smokers, female smokers reported greater negative affect, stress, and craving in response to stressful cues, but not smoking cues, after accounting for time since last cigarette and pre-cue responding. No sex differences in CPD or variability in CPD were detected. Days with higher subjective reactivity to cues were not associated with increased smoking, in either males or females.

CONCLUSIONS

Sex differences were observed in response to stress but not smoking cues in the natural environment of regular cigarette smokers. Further research is necessary to evaluate whether stress reactivity in female smokers is associated with reduced latency to smoke following stress exposure in daily life.

IMPLICATIONS

This study provides naturalistic evidence that female smokers may not be more reactive to smoking cues than males, but experience heightened stress and craving following stress exposure. There was no evidence to support the hypothesis that amount smoked per day varied more for females, relative to males, as a result of more context-driven smoking for females.

Computation of Cigarette Smoke Exposure Metrics From Breathing

Traditional metrics of smoke exposure in cigarette smokers are derived either from self-report, biomarkers, or puff topography. Methods involving biomarkers measure concentrations of nicotine, nicotine metabolites, or carbon monoxide. Puff-topography methods employ portable instruments to measure puff count, puff volume, puff duration, and inter-puff interval. In this article, we propose smoke exposure metrics calculated from the breathing signal and describe a novel algorithm for the computation of these metrics. The Personal Automatic Cigarette Tracker v2 (PACT-2) sensors, puff topography devices (CReSS), and video observation were used in a study of 38 moderate to heavy smokers in a controlled environment. Parameters of smoke inhalation including the start and end of each puff, inhale and exhale cycle, and smoke holding were computed from the breathing signal. From these, the traditional metrics of puff duration, inhale-exhale cycle duration, smoke holding duration, inter-puff interval, and novel Respiratory Smoke Exposure Metrics (RSEMs) such as inhale-exhale cycle volume, and inhale-exhale volume over time were calculated. The proposed RSEM algorithm to extract smoke exposure metrics named generated interclass correlations (ICCs) of 0.85 and 0.87 and Pearson's correlations of 0.97 and 0.77 with video observation and CReSS, respectively, for puff duration. Similarly, for the inhale-exhale duration, an ICC of 0.84 and Pearson's correlation of 0.81 was obtained with video observation. The RSEMs provided measures previously unavailable in research that are proportional to the depth and duration of smoke inhalation. The results suggest that the breathing signal may be used to compute smoke exposure metrics.

A review of EMA assessment period reporting for mood variables in substance use research: Expanding existing EMA guidelines

Ecological Momentary Assessment (EMA) is an increasingly popular approach in substance use research for capturing reliable, in-situ, self-reported information about fluctuating variables, such as mood, over time. Current EMA guidelines do not sufficiently address the reporting of assessment periods (e.g., right now, past 30 min). Given the importance of time in EMA studies, variation and ambiguity in assessment period reporting risks misinterpretation of procedures and findings. The following study reviewed the methodological reporting of EMA assessment periods in substance use research. A search conducted in PsychINFO and PubMed using the terms "ecological momentary assessment" OR "EMA" AND "mood" AND "substance use" yielded 36 unique search results. The references of these results were hand searched and resulted in 126 additional studies. After deleting duplicates and applying inclusion criteria, 56 studies were included in the review. Review of these studies illustrated (1) variability and ambiguity in study assessment periods (2) within-study incongruence between assessment period descriptions and associated EMA prompts, (3) and a large temporal range of retrospective assessment periods across studies. Each of these findings are illustrated and discussed using examples from the literature. From these examples, assessment period reporting guidelines are proposed to improve EMA reporting clarity. Such improvements will facilitate increased synthesis of EMA research and position future researchers to investigate the validity and reliability of EMA data captured with different lengths of retrospection.

Feasibility of Using Ecological Momentary Assessment to Study Unaided Smoking Cessation in Couples

Introduction

Ecological momentary assessment (EMA) is a valuable method for studying smoking cessation, but feasibility has not been examined in committed couples. The current study examines the feasibility of conducting an EMA study of unaided smoking cessation in single-smoker couples.

Methods

Participants were 62 single-smoker couples recruited to participate in a 21-day study of unaided smoking cessation. Quitters and Partners were given instructions to complete one morning report, three signaled reports, and one evening report per day, as well as lapse reports when necessary. They also completed a series of questionnaires at baseline and follow-up. This article examines predictors of compliance with the reporting instructions.

Results

Compliance with scheduled reporting was reasonable (Quitters: 76%, Partners: 79%). Compliance with "on-time" lapse reporting (vs. make-up reporting) was poor (Quitters: 62%, Partners: 43%). Quitters' compliance with lapse reporting was strongly associated with an orientation toward quitting. Partners' compliance with lapse reporting was associated with relationship motivation. Quitter compliance plummeted when Partners were noncompliant. Self-regulation and emotional instability were not associated with compliance but were associated with time to complete reports. Quitters' and Partners' experiences completing the study provide some insight into the dynamics of completing an EMA study as part of a dyad.

Conclusions

Overall, this study suggests it is feasible and effective to collect EMA data on smoking cessation from couples. However, compliance with lapse reporting was poor, especially for Partners. Researchers could provide remuneration on a different schedule, provide shorter lapse reports, or omit Partner lapse reports altogether.

Implications

This article examined compliance with scheduled and lapse reporting in single-smoker couples during an unaided quit attempt. Compliance with scheduled reporting was acceptable, but compliance with lapse reporting was poor, especially for Partners. Quitters' compliance with lapse reporting was heavily influenced by an orientation toward quitting, suggesting that improved screening for motivation to quit might improve compliance rates. Quitter compliance also plummeted when Partners were noncompliant. Partner demographics and relationship motivation were the best predictors of compliance. To enhance compliance, researchers might provide remuneration on a different scale, dramatically shorten lapse reports, or even omit Partner lapse reports.

Combining ecological momentary assessment with objective, ambulatory measures of behavior and physiology in substance-use research

Whereas substance-use researchers have long combined self-report with objective measures of behavior and physiology inside the laboratory, developments in mobile/wearable electronic technology are increasingly allowing for the collection of both subjective and objective information in participants' daily lives. For self-report, ecological momentary assessment (EMA), as implemented on contemporary smartphones or personal digital assistants, can provide researchers with near-real-time information on participants' behavior and mood in their natural environments. Data from portable/wearable electronic sensors measuring participants' internal and external environments can be combined with EMA (e.g., by timestamps recorded on questionnaires) to provide objective information useful in determining the momentary context of behavior and mood and/or validating participants' self-reports. Here, we review three objective ambulatory monitoring techniques that have been combined with EMA, with a focus on detecting drug use and/or measuring the behavioral or physiological correlates of mental events (i.e., emotions, cognitions): (1) collection and processing of biological samples in the field to measure drug use or participants' physiological activity (e.g., hypothalamic-pituitary-adrenal axis activity); (2) global positioning system (GPS) location information to link environmental characteristics (disorder/disadvantage, retail drug outlets) to drug use and affect; (3) ambulatory electronic physiological monitoring (e.g., electrocardiography) to detect drug use and mental events, as advances in machine learning algorithms make it possible to distinguish target changes from confounds (e.g., physical activity). Finally, we consider several other mobile/wearable technologies that hold promise to be combined with EMA, as well as potential challenges faced by researchers working with multiple mobile/wearable technologies simultaneously in the field.

Monitoring smoking behaviour using a wearable acoustic sensor

Smoking is a cause of multiple health problems resulting in diseases which can also be fatal. It is well known that smoking has long-term impact on the health of an individual as well. While a number of studies have looked at the impact of smoking on health and its economic impacts, most of these rely on input from smokers in the form of questionnaires and surveys. Long-term monitoring of smoking habits and behaviour is thus not possible because of the lack of means to do so. This paper proposes the use of a wearable device to monitor breathing signals of subjects. It is shown that the acoustic properties of a smoking breath are different from a non-smoking breath. To encapsulate these differences, several features from a breath segment are extracted and used with a simple classifier to automatically identify smoking breaths. The proposed algorithm detected smoking and non-smoking breaths with average accuracy of 66% and 99% respectively.

Alcohol consumption as a predictor of reactivity to smoking and stress cues presented in the natural environment of smokers

BACKGROUND AND RATIONALE

The high prevalence of co-occurring alcohol and tobacco use underscores the importance of understanding the influence of alcohol consumption on risk factors for smoking and relapse. Alcohol has been shown to impact reactivity to smoking and stress-related cues, both of which are common antecedents to smoking and smoking relapse.

OBJECTIVE

The objective of the current study is to examine associations between alcohol use, cigarette craving, and stress reactivity following exposure to smoking and stress cues delivered in participants' daily lives.

METHODS

Using cue-reactivity ecological momentary assessment (CREMA), adult smokers (n = 138) reported cigarette craving, stress, and past hour alcohol use on a mobile device four times per day for 2 weeks, resulting in a range of 4493-5983 data points per analysis. Questions were followed by exposure to pictorial neutral, stressful, or smoking cues delivered via the mobile device. Craving and affect were re-assessed following cue exposure.

RESULTS

Results showed that recent (past hour) alcohol use was significantly associated with increases in the following: (a) tonic (non-cue-elicited) cigarette craving, (b) stress cue-elicited cigarette craving, and (c) stress cue-elicited stress reactivity, in the context of high-baseline stress. There was no significant association between alcohol use and smoking cue-elicited craving.

CONCLUSIONS

Alcohol use may increase risk for smoking and relapse to smoking by increasing cigarette craving and, in certain contexts, stress following stress cue exposure. Though alcohol is known for its anxiolytic properties, under some conditions, it may increase reactivity to stress cues.

Tobacco cues in India: An ecological momentary assessment

BACKGROUND

Tobacco use in India is a major health concern; however, little is known about the influence of tobacco-related social and environmental cues on tobacco use. This study uses ecological momentary assessment (EMA) to examine real-time tobacco use and exposure to social and environmental cues.

METHODS

In Hyderabad and Kolkata, participants were recruited, and an EMA application was installed on their mobile phones. Momentary prompts (MP) were randomly used to collect real-time information and end-of-day (EOD) prompts gathered retrospective information on daily basis. Besides personal tobacco use, the surveys asked about exposure to social (e.g., presence of others using tobacco) and environmental cues (e.g., visual and olfactory stimuli). Using the data aggregation approach, bivariate and multivariate analyses were performed to examine the association of tobacco use and cue exposure. Moderating roles of participants' socio-demographic characteristics were also tested to gain an in-depth understanding of the relationship.

RESULTS

Among the 205 participants, around a third (MP, 33.7 %; EOD, 37.6 %) used tobacco at least once during the study period. Tobacco-related social and environmental cues related were commonly reported. In the bivariate models, tobacco use was associated with gender, age, and all the examined social and environmental cues except for seeing restrictions on tobacco use. In the multivariate models, tobacco use was associated with age, gender, seeing others using tobacco, and seeing restrictions on tobacco use. Seeing others in one's immediate group using tobacco was the strongest predictor of tobacco use in both MP and EOD assessments. Gender and age did not moderate the relationship between cue exposure and tobacco use, although males reported higher tobacco use and cue exposure in general.

CONCLUSIONS

This research provides data on the ubiquity of social and environmental tobacco cues in India. The EMA approach was feasible and informative. Future cessation interventions and advocacy efforts should address the high prevalence of tobacco use and exposure to pro-tobacco use cues especially among Indian males. Health education campaigns for promoting tobacco use restrictions in private places as well as changing the norms of tobacco use in social settings are recommended.

Point-of-sale cigarette marketing and smoking-induced deprivation in smokers: results from a population-based survey

BACKGROUND

Strict restrictions on outdoor cigarette marketing have resulted in increasing concentration of cigarette marketing at the point-of-sale (POS). The association between POS cigarette marketing and smoking-induced deprivation (SID) has never been studied. The aim of this study was to examine this association and how it is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes.

METHODS

Data from a telephone survey of 939 smokers were collected in Omaha, Nebraska. POS cigarette marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions such as cigarette price discounts within their respective neighborhoods. SID was measured with the following question: "In the last six months, has there been a time when the money you spent on cigarettes resulted in not having enough money for household essentials such as food? [yes/no]" We used structural equation modeling to examine the study aim.

RESULTS

There was overwhelming evidence for an association between higher levels of POS cigarette marketing and a higher probability of SID (p < 0.001). This association was partly mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes during a visit to a neighborhood store (p < 0.001).

CONCLUSION

Given that POS cigarette marketing is associated with a higher probability of experiencing SID, policies that ban POS cigarette marketing might help some smokers afford essentials household items such as food more easily and thus have better standards of living.

Does laboratory cue reactivity correlate with real-world craving and smoking responses to cues?

BACKGROUND

Laboratory cue reactivity (CR) assessments are used to assess smokers' responses to cues. Likewise, EMA recording is used to characterize real-world response to cues. Understanding the relationship between CR and EMA responses addresses the ecological validity of CR.

METHODS

In 190 daily smokers not currently quitting, craving and smoking responses to cues were assessed in laboratory CR and by real-world EMA recording. Separate CR sessions involved 5 smoking-relevant cues (smoking, alcohol, negative affect, positive affect, smoking prohibitions), and a neutral cue. Subjects used EMA to monitor smoking situations for 3 weeks, completing parallel situational assessments (presence of others smoking, alcohol consumption, negative affect, positive affect, and smoking prohibitions, plus current craving) in smoking and non-smoking occasions (averaging 70 and 60 occasions each). Analyses correlated CR craving and smoking cue responses with EMA craving and smoking correlations with similar cues.

RESULTS

Although some cues did not show main effects on average craving or smoking, a wide range of individual differences in response to cues was apparent in both CR and EMA data, providing the necessary context to assess their relationship. Laboratory CR measures of cue response were not correlated with real-world cue responses assessed by EMA. The average correlation was 0.03; none exceeded 0.32. One of 40 correlations examined was significantly greater than 0.

CONCLUSIONS

Laboratory CR measures do not correlate with EMA-assessed craving or smoking in response to cues, suggesting that CR measures are not accurate predictors of how smokers react to relevant stimuli in the real world.

Gender differences in responses to cues presented in the natural environment of cigarette smokers

INTRODUCTION

Although the evidence is mixed, female smokers appear to have more difficulty quitting smoking than male smokers. Craving, stress, and negative affect have been hypothesized as potential factors underlying gender differences in quit rates.

METHODS

In the current study, the cue-reactivity paradigm was used to assess craving, stress, and negative affect in response to cues presented in the natural environment of cigarette smokers using ecological momentary assessment. Seventy-six daily smokers (42% female) responded to photographs (smoking, stress, and neutral) presented 4 times per day on an iPhone over the course of 2 weeks.

RESULTS

Both smoking and stress cues elicited stronger cigarette craving and stress responses compared to neutral cues. Compared with males, females reported higher levels of post-stress cue craving, stress, and negative affect, but response to smoking cues did not differ by gender.

DISCUSSION

Findings from this project were largely consistent with results from laboratory-based research and extend previous work by measuring response to cues in the natural environment of cigarette smokers. This study extends previous cue reactivity ecological momentary assessment research by using a new platform and by measuring response to stress cues outside of the laboratory. Findings from this project highlight the importance of addressing coping in response to stress cues in clinical settings, especially when working with female smokers.

Using Ecological Momentary Assessment to Study Tobacco Behavior in Urban India: There's an App for That

Background

Ecological momentary assessment (EMA) uses real-time data collection to assess participants’ behaviors and environments. This paper explores the strengths and limitations of using EMA to examine social and environmental exposure to tobacco in urban India among older adolescents and adults.

Objective

Objectives of this study were (1) to describe the methods used in an EMA study of tobacco use in urban India using a mobile phone app for data collection, (2) to determine the feasibility of using EMA in the chosen setting by drawing on participant completion and compliance rates with the study protocol, and (3) to provide recommendations on implementing mobile phone EMA research in India and other low- and middle-income countries.

Methods

Via mobile phones and the Internet, this study used two EMA surveys: (1) a momentary survey, sent multiple times per day at random to participants, which asked about their real-time tobacco use (smoked and smokeless) and exposure to pro- and antitobacco messaging in their location, and 2) an end-of-day survey sent at the end of each study day. Trained participants, from Hyderabad and Kolkata, India, reported on their social and environmental exposure to tobacco over 10 consecutive days. This feasibility study examined participant compliance, exploring factors related to the successful completion of surveys and the validity of EMA data.

Results

The sample included 205 participants, the majority of whom were male (135/205, 65.9%). Almost half smoked less than daily (56/205, 27.3%) or daily (43/205, 21.0%), and 4.4% (9/205) used smokeless tobacco products. Participants completed and returned 46.87% and 73.02% of momentary and end-of-day surveys, respectively. Significant predictors of momentary survey completion included employment and completion of end-of-day surveys. End-of-day survey completion was only significantly predicted by momentary survey completion.

Conclusions

This first study of EMA in India offers promising results, although more research is needed on how to increase compliance. End-of-day survey completion, which has a lower research burden, may be the more appropriate approach to understanding behaviors such as tobacco use within vulnerable populations in challenging locations. Compliance may also be improved by increasing the number of study visits, compliance checks, or opportunities for retraining participants before and during data collection.

The association of point-of-sale cigarette marketing with cravings to smoke: results from a cross-sectional population-based study

OBJECTIVE

To examine the association between recalled exposure to point-of-sale (POS) cigarette marketing (ie, pack displays, advertisements and promotions such as discounts) and reported cravings to smoke while visiting a store.

METHODS

Data were collected using a telephone survey of a cross-sectional sample of 999 adult smokers in Omaha, Nebraska. Recalled exposure to POS cigarette marketing was measured by asking respondents about noticing (a) pack displays, (b) advertisements and (c) promotions in store in their neighbourhood. A 3-item scale indicating the frequency of experiencing cravings to smoke in locations where cigarettes are sold was created by asking respondents: (1) "feel a craving for a cigarette?" (2) "feel like nothing would be better than smoking a cigarette?" and (3) "feel like all you want is a cigarette?" The association between recalled exposure to POS cigarette marketing and cravings was estimated using ordinary least squares linear regression models, controlling for nicotine dependence, gender, age, race/ethnicity, income, education, frequency of visiting stores in one's neighbourhood and method of recruitment into the study.

RESULTS

Recalled exposure to POS cigarette displays (p<0.001) and advertisements (p=0.002), but not promotions (p=0.06), was associated with more frequent cravings to smoke.

CONCLUSIONS

Recalled exposure to POS cigarette marketing is associated with cravings to smoke as predicted by laboratory studies on the effects of smoking cues on cigarette craving. Policies that reduce or eliminate POS cigarette marketing could reduce cigarette cravings and might attenuate impulse buying of cigarettes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A wearable sensor system for monitoring cigarette smoking

OBJECTIVE

Available methods of smoking assessment (e.g., self-report, portable puff-topography instruments) do not permit the collection of accurate measures of smoking behavior while minimizing reactivity to the assessment procedure. This article suggests a new method for monitoring cigarette smoking based on a wearable sensor system (Personal Automatic Cigarette Tracker [PACT]) that is completely transparent to the end user and does not require any conscious effort to achieve reliable monitoring of smoking in free-living individuals.

METHOD

The proposed sensor system consists of a respiratory inductance plethysmograph for monitoring of breathing and a hand gesture sensor for detecting a cigarette at the mouth. The wearable sensor system was tested in a laboratory study of 20 individuals who performed 12 different activities including cigarette smoking. Signal processing was applied to evaluate the uniqueness of breathing patterns and their correlation with hand gestures.

RESULTS

The results indicate that smoking manifests unique breathing patterns that are highly correlated with hand-to-mouth cigarette gestures and suggest that these signals can potentially be used to identify and characterize individual smoke inhalations.

CONCLUSIONS

With the future development of signal processing and pattern-recognition methods, PACT can be used to automatically assess the frequency of smoking and inhalation patterns (such as depth of inhalation and smoke holding) throughout the day and provide an objective method of assessing the effectiveness of behavioral and pharmacological smoking interventions.

Resisting the urge to smoke and craving during a smoking quit attempt on varenicline: results from a pilot fMRI study

BACKGROUND

Varenicline has been shown to reduce cigarette craving during a quit attempt.

OBJECTIVES

Use BOLD fMRI to explore differences in smoking cue reactivity at baseline and after five weeks of varenicline smoking cessation treatment.

METHODS

Treatment-seeking nicotine-dependent adult smokers underwent BOLD fMRI scans with block presentation of visual smoking, neutral, and rest cues under two conditions: craving or resisting the urge to smoke at baseline and following 5 weeks of standard varenicline therapy. Data were analyzed using FMRI Expert Analysis Tool, version 5.98 of Functional Magnetic Imaging of the Brain Software Library focused on the smoking vs. neutral cue contrast at the individual and group level, Z>2.3 with cluster threshold p=0.05.

RESULTS

Twenty-one participants were scanned at baseline and 16 completed the study; 10 were abstinent at the 2(nd) session, confirmed with urinary cotinine. In the Crave Condition no significant differences were found between the abstinent and non-abstinent groups at either time point. During the baseline Resist Condition, the abstinent group compared to the non-abstinent group demonstrated activation in a distributed network involved in alertness, learning and memory. Additionally, within the abstinent group, increased activation of the superior frontal gyrus was found at baseline compared to week 5.

CONCLUSION

Successful smoking cessation with varenicline is associated with increased activation, prior to a quit attempt, in brain areas related to attentiveness and memory while resisting the urge to smoke Scientific Significance: Varenicline may exert effects by both reducing craving and enhancing resistance to smoking urges during cue-elicited craving.

The magnitude and reliability of cue-specific craving in nondependent smokers

BACKGROUND

Cue-reactivity is a robust phenomenon in regular cigarette smokers (Carter and Tiffany, 1999), but it has not been widely investigated in nondependent smokers. Further, most research on cue-specific craving assesses response to cues in a single experimental session. As such, investigations of cue-specific craving have primarily measured state-like but not trait-like responses to smoking stimuli.

METHODS

This study measured general and cue-specific craving in nondependent smokers and assessed the within-session and cross-session reliability of these two facets of craving. Participants (n=154) attended five laboratory sessions over the course of three months and completed multiple cue-reactivity trials (using smoking and neutral in vivo and photographic stimuli) during each study visit.

RESULTS

Results indicated that smoking cues elicited significantly stronger craving than neutral cues across study sessions, and that craving ratings following smoking cues decreased across subsequent sessions. Within-session and cross-session reliability was extremely high.

CONCLUSIONS

Overall, findings indicate that nondependent smokers experience reactivity to smoking cues, and that this response is quite reliable within and across sessions. Further, the magnitude of cue-specific craving was comparable to what has been observed in heavy, dependent smokers.

Conceptualizing analyses of ecological momentary assessment data

Ecological momentary assessment (EMA) methods, which involve collection of real-time data in subjects' real-world environments, are particularly well suited to studying tobacco use. Analyzing EMA datasets can be challenging, as the datasets include a large and varied number of observations per subject and are relatively unstructured. This paper suggests that time is typically a key organizing principle in EMA data and that conceptualizing the data as a timeline of events, behaviors, and experiences can help define analytic approaches. EMA datasets lend themselves to answering a diverse array of research questions, and the research question must drive how data are arranged for analysis, and the kinds of statistical models that are applied. This is illustrated this with brief examples of diverse analyses applied to answer different questions from an EMA study of tobacco use and relapse.

Craving effect of smoking cues in smoking and antismoking stimuli in light smokers

Cue-reactivity models may be able to inform light and intermittent smoking patterns not yet explained by withdrawal models. For instance, smoking cues in smoking and antismoking advertisements may elicit cravings in smokers at equal rates, which may promote smoking maintenance. Moreover, smoking has been associated with impulsivity, but has not been explored in light and intermittent smokers (LITS). Aims of this study included the assessment of the impact of smoking and antismoking advertisements on post-exposure cravings in LITS and assessment of impulsivity as a moderator between cue exposure and cravings. Data from 155 LITS were analyzed. Participants were exposed to one of three stimuli conditions (i.e., smoking, antismoking, and neutral) and completed measures of demographics, tobacco use and history, impulsivity, and cravings. Univariate analysis demonstrated that smoking stimuli produced higher cravings relative to antismoking and neutral stimuli, whereas no differences between antismoking and neutral stimuli were observed. Impulsivity did not moderate the relationship between stimuli condition and cravings. Implications stemming from these findings include the further regulation of smoking advertisements and future exploration of smoking and smoking cessation in the context of cue-reactivity.

Cognition and craving during smoking cessation: an ecological momentary assessment study

INTRODUCTION

Some studies using ecological momentary assessment (EMA) have revealed an association between craving for cigarettes and relapse. It is therefore important to understand the correlates of craving during smoking cessation. Attentional bias to smoking cues is a potential correlate of craving, but it has not previously been assessed using EMA during smoking cessation.

METHODS

Smokers enrolled in a research smoking cessation study were offered the opportunity to take part in an EMA study. Volunteers carried around a personal digital assistant (PDA) for the first week of their quit attempt. They completed up to 4 random assessments (RAs) per day as well as assessments when they experienced a temptation to smoke and when they relapsed. Craving for cigarettes was assessed with a single item (1-7 scale). Attentional bias was assessed with a smoking Stroop task (a reaction time task) at every other assessment, as was self-reported attention to cigarettes.

RESULTS

Data were available from 119 participants. Across 882 assessments, participants exhibited a significant smoking Stroop effect. Linear mixed models revealed a significant between-subject association between craving and the smoking Stroop effect. Individuals with higher levels of craving exhibited greater attentional bias. The within-subject association was not significant. Similar results were obtained for the relationship between self-reported attention to cigarettes and attentional bias.

CONCLUSIONS

Attentional bias can be assessed in the natural environment using EMA during smoking cessation, and attentional bias is a correlate of craving during the early stages of a quit attempt.

Cue-induced cigarette craving and mixed emotions: a role for positive affect in the craving process

Craving is an important component of nicotine addiction, and extant research has demonstrated a clear link between cue-induced craving and negative affect, with mixed results in the positive affect domain. The current study was designed to test the idea that cue-reactive craving might be associated with a mixed emotional process, or the simultaneous experience of positive and negative affect. Participants were 86 non-deprived regular smokers and tobacco chippers who provided simultaneous ratings of positive and negative affect during cue exposure to pleasant, unpleasant, neutral and cigarette cues. Results indicated that self-reported craving was elevated in response to cigarette cues compared to other valenced cue types and craving was higher to pleasant cues than either neutral or unpleasant cues. Mixed emotional responses were higher to cigarette cues than other cue types. In addition, mixed emotional responses to cigarette cues predicted craving even after controlling for smoker type, difficulties regulating negative emotion, baseline craving level and mixed emotional responses to neutral cues. As the first study to investigate mixed emotions and cigarette craving, our results highlight the importance of examining the relationship between cue-reactive craving and emotional response using models of emotion that allow for measurement of nuanced emotional experience. In addition, our findings suggest that positive affect processes may indeed play a role in craving among non-deprived smokers.

Cue reactivity in non-daily smokers: effects on craving and on smoking behavior

RATIONALE

Non-daily, or intermittent smokers (ITS), are increasingly prevalent. Their smoking may be more situational than that of daily smokers (DS), and thus is hypothesized to be more influenced by cues.

OBJECTIVES

To assess ITS' response to cues, and compare it to that of DS.

METHODS

Samples of 239 ITS and 207 DS (previously reported in Shiffman et al. 2012a) were studied in 2,586 laboratory cue-reactivity sessions. Craving (Questionnaire of Smoking Urges) and smoking (probability, latency, puff parameters, and carbon monoxide increases) in response to cues was assessed following exposure to neutral cues and cues related to smoking, alcohol, negative affect, positive affect, and smoking prohibitions. Mixed effects models, generalized estimating equations and random-effects survival analyses were used to assess response to cues and differences between DS and ITS.

RESULTS

ITS' craving increased following exposure to smoking and alcohol cues and decreased following positive affect cues, but cues had little effect on smoking behaviors. Cue reactivity was similar in ITS and DS. Among ITS, craving intensity predicted smoking probability, latency, and intensity, and the effects on latency were stronger among ITS than DS.

CONCLUSIONS

Contrary to hypotheses, ITS were not more responsive to laboratory cues than DS. Results show that ITS do experience craving and craving increases that are then associated with smoking.

Monitoring of cigarette smoking using wearable sensors and support vector machines

Cigarette smoking is a serious risk factor for cancer, cardiovascular, and pulmonary diseases. Current methods of monitoring of cigarette smoking habits rely on various forms of self-report that are prone to errors and under reporting. This paper presents a first step in the development of a methodology for accurate and objective assessment of smoking using noninvasive wearable sensors (Personal Automatic Cigarette Tracker-PACT) by demonstrating feasibility of automatic recognition of smoke inhalations from signals arising from continuous monitoring of breathing and hand-to-mouth gestures by support vector machine classifiers. The performance of subject-dependent (individually calibrated) models was compared to performance of subject-independent (group) classification models. The models were trained and validated on a dataset collected from 20 subjects performing 12 different activities representative of everyday living (total duration 19.5 h or 21,411 breath cycles). Precision and recall were used as the accuracy metrics. Group models obtained 87% and 80% of average precision and recall, respectively. Individual models resulted in 90% of average precision and recall, indicating a significant presence of individual traits in signal patterns. These results suggest the feasibility of monitoring cigarette smoking by means of a wearable and noninvasive sensor system in free living conditions.

Smoker reactivity to cues: effects on craving and on smoking behavior

We assessed craving and smoking in response to smoking-relevant cues. Two hundred seven daily smokers viewed images related to 1 of 6 cue sets (cigarettes, positive and negative affect, alcohol, smoking prohibitions, and neutral cues) in separate sessions. Compared with neutral cues, cigarette cues significantly increased craving, and positive affect cues significantly decreased craving. When subjects were then allowed to smoke during continuing cue exposure, cues did not affect the likelihood of smoking or the amount smoked (number of cigarettes, number of puffs, puff time, or increased carbon monoxide). However, craving intensity predicted likelihood of smoking, latency to smoke, and amount smoked, with craving increases after cue exposure making significant independent contributions. Some craving effects were curvilinear, suggesting that they are subject to thresholds and might not be observed under some circumstances.

Impact of varenicline on cue-specific craving assessed in the natural environment among treatment-seeking smokers

RATIONALE

Varenicline is believed to work, in part, by reducing craving responses to smoking cues and by reducing general levels of craving; however, these hypotheses have never been evaluated with craving assessed in the natural environments of treatment-seeking smokers.

OBJECTIVES

Ecological momentary assessment procedures were used to assess the impact of varenicline on cue-specific and general craving in treatment-seeking smokers prior to quitting.

METHODS

For 5 weeks prior to quitting, 60 smokers carried personal digital assistants that assessed their response to smoking or neutral cues. During week 1 (baseline), participants did not receive medication; during weeks 2-4 (drug manipulation), participants were randomized to receive varenicline or placebo; during week 5 (standard therapy), all participants received varenicline. Craving was assessed before each cue; cue-specific craving and attention to cue were assessed after each cue.

RESULTS

During all phases, smoking cues elicited greater craving than neutral cues; the magnitude of this effect declined after the first week. General craving declined across each phase of the study. Relative to the placebo condition, varenicline was associated with a greater decline in general craving over the drug manipulation phase. Varenicline did not significantly attenuate cue-specific craving during any phase of the study.

CONCLUSIONS

Smoking cues delivered in the natural environment elicited strong craving responses in treatment-seeking smokers, but cue-specific craving was not affected by varenicline administered prior to the quit attempt. These findings suggest that the clinical efficacy of varenicline is not mediated by changes in cue-specific craving during the pre-quit period of treatment-seeking smokers.

Neural correlates of craving and resisting craving for tobacco in nicotine dependent smokers

Craving is a significant factor which can lead to relapse during smoking quit attempts. Attempts to resist urges to smoke during cue-elicited craving have been shown to activate regions in the brain associated with decision-making, anxiety regulation and visual processing. In this study, 32 treatment-seeking, nicotine-dependent smokers viewed blocks of smoking and neutral cues alternating with rest periods during magnetic resonance imaging scanning in a 3T Siemens scanner (Siemens AG, Erlangen, Bavaria, Germany). While viewing cues or control images, participants were instructed either to 'allow yourself to crave' or 'resist craving.' Data were analyzed with FSL 4.1.5, focused on the smoking cues versus neutral cues contrast, using cluster thresholding (Z > 2.3 and corrected cluster threshold of P = 0.05) at the individual and group levels. During the Crave condition, activation was seen on the left anterior cingulated cortex (LACC), medial prefrontal cortex, left middle cingulate gyrus, bilateral posterior cingulated gyrus and bilateral precuneus, areas associated with attention, decision-making and episodic memory. The LACC and areas of the prefrontal cortex associated with higher executive functioning were activated during the Resist condition. No clear distinctions between group crave and resist analyses as a whole were seen without taking into account specific strategies used to resist the urge to smoke, supporting the idea that craving is associated with some degree of resisting the urge to smoke, and trying to resist is almost always accompanied by some degree of craving. Different strategies for resisting, such as distraction, activated different regions. Understanding the underlying neurobiology of resisting craving to smoke may identify new foci for treatments.

Cue-reactivity in the natural environment of cigarette smokers: the impact of photographic and in vivo smoking stimuli

The cue-reactivity paradigm has been used extensively in laboratory settings to study cue-specific craving responses to drug-related cues. However, this procedure has been used in only one study to assess craving in the drug user's natural environment (Warthen & Tiffany, 2009). The present study combined cue-reactivity with ecological momentary assessment (CREMA) to evaluate smokers' cue reactions in natural environments as a further validation and extension of this procedure. A total of 66 daily cigarette smokers carried a personal digital assistant (PDA) and had the opportunity to respond to 32 cue-reactivity sessions across 8 days. Cues were presented through in vivo and photographic modes. During in vivo sessions, participants handled and looked at a cigarette or neutral object, while during photographic sessions, participants looked at a smoking-related or neutral photograph on the PDA. Craving and mood were assessed before and after cue presentations. Cues were also presented in the laboratory both before (Lab I) and after (Lab II) the 8-day CREMA procedure. Participants completed over 90% of cue-reactivity sessions delivered with the CREMA procedure. Analyses revealed robust cue-reactivity in the natural environment and laboratory across both modes of presentation. Photographic cues elicited significantly stronger cue-reactivity effects than in vivo cues across all sessions. The CREMA procedure has been shown to elicit robust cue-reactivity effects across multiple modes of cue presentation. Results support the use of the CREMA procedure for examining cue-specific craving in the natural environment of smokers.

Consumption of single cigarettes and quitting behavior: a longitudinal analysis of Mexican smokers

BACKGROUND

Previous cross-sectional research has suggested single cigarettes could either promote or inhibit consumption. The present study aimed to assess the effects of single cigarette availability and consumption on downstream quit behavior.

METHODS

We analyzed population-based, longitudinal data from adult smokers who participated in the 2008 and 2010 administrations of the International Tobacco Control Policy Evaluation Survey in Mexico.

RESULTS

At baseline, 30% of smokers saw single cigarettes for sale on a daily basis, 17% bought singles at their last purchase, and 7% bought singles daily. Smokers who most frequently purchased singles, both in general and specifically to control their consumption, were no more likely to attempt to quit over the 14 month follow-up period than those who did not purchase singles. Frequency of buying singles to reduce consumption had a non-monotonic association with being quit at followup. The odds of being quit was only statistically significant when comparing those who had not bought singles to reduce consumption with those who had done so on a more irregular basis (AOR = 2.30; 95% CI 1.19, 4.45), whereas those who did so more regularly were no more likely to be quit at followup. Frequency of self-reported urges to smoke upon seeing singles for sale was unassociated with either quit attempts or being quit at followup.

CONCLUSIONS

These results suggest that the relationship between singles consumption and quit behavior is complex, with no clear evidence that singles either promote or inhibit downstream quit behavior.

Nicotine competes with a visual stimulus for control of conditioned responding

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

Counterbalancing in smoking cue research: a critical analysis

INTRODUCTION

Cue exposure research has been used to examine key issues in smoking research, such as predicting relapse, testing new medications, investigating the neurobiology of nicotine dependence, and examining reactivity among smokers with comorbid psychopathologies. Determining the order that cues are presented is one of the most critical steps in the design of these investigations. It is widely assumed that cue exposure studies should counterbalance the order in which smoking and control (neutral) cues are presented. This article examines the premises underlying the use of counterbalancing in experimental research, and it evaluates the degree to which counterbalancing is appropriate in smoking cue exposure studies.

METHODS

We reviewed the available literature on the use of counterbalancing techniques in human smoking cue exposure research.

RESULTS

Many studies counterbalancing order of cues have not provided critical analyses to determine whether this approach was appropriate. Studies that have reported relevant data, however, suggest that order of cue presentation interacts with type of cue (smoking vs. control), which raises concerns about the utility of counterbalancing. Primarily, this concern arises from potential carryover effects, in which exposure to smoking cues affects subsequent responding to neutral cues.

CONCLUSIONS

Cue type by order of cue interactions may compromise the utility of counterbalancing. Unfortunately, there is no obvious alternative that is optimal across studies. Strengths and limitations of several alternative designs are considered, and key questions are identified to advance understanding of the optimal conditions for conducting smoking cue exposure studies.

Identifying specific cues and contexts related to smoking craving for the development of effective virtual environments

Craving is considered the main variable associated with relapse after smoking cessation. Cue Exposure Therapy (CET) consists of controlled and repeated exposure to drug-related cues with the aim of extinguishing craving responses. Some virtual reality (VR) environments, such as virtual bars or parties, have previously shown their efficacy as tools for eliciting smoking craving. However, in order to adapt this technology to smoking cessation interventions, there is a need for more diverse environments that enhance the probability of generalization of extinction in real life. The main objective of this study was to identify frequent situations that produce smoking craving, as well as detecting specific craving cues in those contexts. Participants were 154 smokers who responded to an ad hoc self-administered inventory for assessing craving level in 12 different situations. Results showed that having a drink in a bar/pub at night, after having lunch/dinner in a restaurant and having a coffee in a cafe or after lunch/dinner at home were reported as the most craving-inducing scenarios. Some differences were found with regard to participants' gender, age, and number of cigarettes smoked per day. Females, younger people, and heavier smokers reported higher levels of craving in most situations. In general, the most widely cited specific cues across the contexts were people smoking, having a coffee, being with friends, and having finished eating. These results are discussed with a view to their consideration in the design of valid and reliable VR environments that could be used in the treatment of nicotine addicts who wish to give up smoking.

Prolonged duration of craving, mood, and autonomic responses elicited by cues and imagery in smokers: Effects of tobacco deprivation and sex

Increases in self-reported craving and changes in autonomic functioning are reliably elicited when smokers are exposed to tobacco-related stimuli compared with neutral stimuli. However, few studies have reported the time course of cue-elicited craving or have directly compared the effectiveness of smoking cues versus imagery to evoke a craving response. In addition to these two issues, we investigated the influence of tobacco deprivation and sex on craving, mood, and autonomic responses. Sixty cigarette smokers (30 men, 30 women) were tested in two counterbalanced sessions, one after overnight tobacco deprivation and one during ad libitum smoking. At each session, participants were exposed to four randomized experimental trials: smoking imagery, neutral imagery, smoking cues, and neutral cues. Tobacco craving and mood were assessed repeatedly and physiological measures were recorded continuously for 30 min after imagery or cue exposure. Compared with neutral trials, smoking cues and smoking imagery reliably increased tobacco craving, negative mood, heart rate, and blood pressure and decreased positive mood ratings. Changes were observed immediately after cue and imagery presentation and remained unchanged for 30 min. Responding was greater in the nondeprived condition, and cues elicited more robust responding than imagery for most measures. Women responded more robustly to smoking cues only in the nondeprived condition, whereas imagery evoked greater responses in men during both conditions. These findings provide new data on the time course, magnitude, and tobacco deprivation effects on elicited craving. Sex differences were dependent on stimulus type and deprivation condition.

The impact of cigarette deprivation and cigarette availability on cue-reactivity in smokers

AIMS

This experiment was conducted to determine the impact of cigarette deprivation and cigarette availability on reactivity measures to cigarette cues.

PARTICIPANTS

Smokers were recruited who were 18 years of age or older, not attempting to quit or cut down on their smoking, smoked at least 20 cigarettes daily, had been smoking regularly for past year and had an expired carbon monoxide level of at least 10 parts per million.

DESIGN

Smokers were assigned randomly to abstain from smoking for 24 hours (n = 51) or continue smoking their regular amount (n = 50). Twenty-four hours later, they were exposed to trials of either a lit cigarette or a glass of water with a 0, 50 or 100% probability of being able to sample the cue on each trial. Craving, mood, heart rate, skin conductance, puff topography and latency to access door to sample the cue were measured.

FINDINGS

Both exposure to cigarette cues and increasing availability of those cues produced higher levels of craving to smoke. Deprivation produced a generalized increase in craving. There was no consistent evidence, however, that even under conditions of high cigarette availability, deprived smokers were sensitized selectively to presentations of cigarette cues.

CONCLUSIONS

The data suggest that, even under conditions of immediate cigarette availability, deprivation and cue presentations have independent, additive effects on self-reported craving levels in smokers.

Does the availability of single cigarettes promote or inhibit cigarette consumption? Perceptions, prevalence and correlates of single cigarette use among adult Mexican smokers

BACKGROUND

Single cigarette use and its implications have rarely been studied among adults.

OBJECTIVE

To assess perceptions, prevalence and correlates of single cigarette purchase behaviour and its relation to harm reduction.

DESIGN

Focus group transcripts and cross-sectional data were analysed.

SETTING AND PARTICIPANTS

Focus groups among convenience samples of adult smokers in two Mexican cities and a population-based sample of 1079 adult smokers from the International Tobacco Control Policy Evaluation Project in four Mexican cities.

MAIN OUTCOME MEASURES

Purchase of single cigarettes last time cigarettes were bought, frequency of purchasing single cigarettes in the previous month and intention to quit in the next 6 months.

RESULTS

Focus group data indicated that smokers bought single cigarettes as a harm reduction strategy. Survey data indicated that 38% of participants purchased single cigarettes in the last month and 10% purchased them the last time they bought cigarettes, with more frequent consumption among young adults and those with lower income. Purchasing single cigarettes was independently associated with the frequency of using single cigarettes to reduce consumption and, less consistently, with the frequency of being cued to smoke after seeing single cigarettes for sale. Using single cigarettes to reduce consumption was positively associated with quit intention, whereas being cued to smoke by single cigarettes was negatively associated with quit intention.

CONCLUSIONS

Study results suggest that some adult Mexican smokers purchase single cigarettes as a method to limit, cut down on and even quit smoking. Nevertheless, promotion of the availability of single cigarettes as a harm reduction strategy could provide additional smoking cues that undermine quit attempts and promote youth smoking.

Cocaine craving and use during daily life

RATIONALE

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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