Craving to quit: psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions

Smartband-based smoking detection and real-time brief mindfulness intervention: findings from a feasibility clinical trial

BACKGROUND

Smartbands can be used to detect cigarette smoking and deliver real time smoking interventions. Brief mindfulness interventions have been found to reduce smoking.

OBJECTIVE

This single arm feasibility trial used a smartband to detect smoking and deliver brief mindfulness exercises.

METHODS

Daily smokers who were motivated to reduce their smoking wore a smartband for 60 days. For 21 days, the smartband monitored, detected and notified the user of smoking in real time. After 21 days, a 'mindful smoking' exercise was triggered by detected smoking. After 28 days, a 'RAIN' (recognize, allow, investigate, nonidentify) exercise was delivered to predicted smoking. Participants received mindfulness exercises by text message and online mindfulness training. Feasibility measures included treatment fidelity, adherence and acceptability.

RESULTS

Participants (N=155) were 54% female, 76% white non-Hispanic, and treatment starters (n=115) were analyzed. Treatment fidelity cutoffs were met, including for detecting smoking and delivering mindfulness exercises. Adherence was mixed, including moderate smartband use and low completion of mindfulness exercises. Acceptability was mixed, including high helpfulness ratings and mixed user experiences data. Retention of treatment starters was high (81.9%).

CONCLUSIONS

Findings demonstrate the feasibility of using a smartband to track smoking and deliver quit smoking interventions contingent on smoking.

Sex differences in cigarette smoking following a mindfulness-based cessation randomized controlled trial

Some interventions for smoking cessation such as quit smoking aids show sex-specific effects on outcomes, but behavioral interventions such as mindfulness-based interventions (MBIs) for smoking cessation lack formal reporting of sex-intervention tests of interaction to date. To address this gap, we conducted a secondary analysis of a RCT dataset (N = 213), recruiting participants from California, to statistically test a sex-intervention interaction effect on complete 7-day point prevalence abstinence (PPA), proportion of days abstinent, and daily cigarettes smoked. Smoking was assessed using the timeline follow back method spanning the four weeks following a daily 14-day app-based intervention and a planned smoking quit date immediately following the intervention phase. All models adjusted for baseline nicotine dependence. The study groups had comparable sex proportions (MBI: 56 % female; control: 55 % female) and the ratio of outcome assessment completion by group was not dependent on sex. Adjusted analyses revealed a significant sex-intervention interaction effect for daily cigarettes smoked ([female coded 1]: two-way interaction effect IRR = 0.59, 95 % CI: 0.46-0.77, p < 0.0001; effect for female: IRR = 0.68, 95 % CI: 0.57-0.81, effect for male: IRR = 1.14, 95 % CI: 0.95-1.37), but not for complete 7-day PPA ([female coded 1] two-way interaction effect OR = 1.24, 95 % CI: 0.31-4.89, p = 0.76) or proportion of total days abstinent ([female coded 1] two-way interaction effect OR = 1.97, 95 % CI: 0.53-7.37, p = 0.31). Females, but not males, allocated to a daily app-based MBI with a quit plan and quit aid workbook smoked fewer cigarettes per day compared to females in the control group. Males, but not females, showed significantly less use of the MBI app compared to the control app.

The moderating role of food cravings in the relationship between weight suppression and eating disorder psychopathology in college students

Weight suppression (WS), the difference between an individual's current and highest adult weight, is predictive of eating-related pathology across diagnostic categories and poor eating disorder treatment outcomes, but findings from non-clinical samples have been mixed. Cravings are strong urges for specific foods that are subjectively difficult to resist. Food cravings are now widely conceptualized as cognitive-affective states characterized by intrusive thoughts that are perceived as distressing and can interfere with adaptive functioning. Food cravings are known antecedents of binge eating, but little is known about how they interact with WS. We examined the obsessive-compulsive aspects of food cravings as potential moderators of the association between WS and eating disorder symptoms in general, and binge eating specifically in a cross-sectional study of college students. Participants (n = 144, 60.4% female) self-reported their height and current and past highest adult weight and completed the Binge Eating Scale (BES), Eating Disorder Examination-Questionnaire (EDE-Q), and Obsessive Compulsive Eating Scale (OCES). Main and interactive effects of WS and OCES scores on EDE-Q global and BES scores were examined in regression models. There were significant main effects of OCES scores on overall eating disorder symptom severity as well as binge frequency, with those endorsing more craving-related intrusive thoughts and compulsive urges engaging in maladaptive behaviors more frequently. WS alone did not consistently cross-sectionally predict eating disorder psychopathology. Findings suggest that food cravings are significantly associated with disordered eating symptoms and specifically binge eating frequency and should be accounted for in future research on WS in clinical and non-clinical samples.

Commentary With Study Protocol: Implementation and Effectiveness of Mindfulness-Oriented Recovery Enhancement (MORE) as an Adjunct to Methadone Treatment for Opioid Use Disorder (IMPOWR-MORE)

Traditional methadone treatment (MT) for opioid use disorder (OUD) fails to systematically address the physical pain, emotion dysregulation, and reward processing deficits that co-occur with OUD, and novel interventions that address these issues are needed to improve MT outcomes. Mindfulness-Oriented Recovery Enhancement (MORE) remediates the hedonic dysregulation in brain reward systems that is associated with OUD. Our pilot and phase 2 randomized controlled trials of MORE were the first to demonstrate MORE's feasibility, acceptability, and efficacy as delivered in MT clinics; MORE significantly reduced drug use (eg, benzodiazepines, barbiturates, cocaine, marijuana, opioids, and other drugs), craving, depression, anxiety, and pain among people with OUD. However, uptake of novel, efficacious interventions like MORE may be slow in MT because time and resources are often limited. Therefore, to best address potential implementation issues and to optimize future MORE implementation and dissemination, in this study, we will utilize a Type 2, Hybrid Implementation-Effectiveness study design. We will not only evaluate MORE's effectiveness but also assess barriers and facilitators to integrating MORE into MT. MT clinicians will receive training in (1) a higher intensity MORE implementation strategy consisting of training in the full MORE treatment manual or (2) a minimal intensity implementation strategy consisting of a simple, scripted mindfulness practice (SMP) extracted from the MORE treatment manual with minimal training. We aim to: (1) using a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, examine barriers and facilitators to implementation of MORE and SMP in MT, and evaluate strategies for optimizing training, fidelity, and engagement, (2) optimize existing MORE and SMP training and implementation toolkits, including adaptable resources that can accelerate the translation of evidence into practice, and (3) compared to usual MT, evaluate the relative effectiveness of MORE plus MT or SMP plus MT (N = 450).

Is life going too fast? Exploring the unique and joint contributions of mindfulness, temperament, task load, and metacognitions about time

BACKGROUND

Previous research has shown that mindfulness is associated with slower passage of time in everyday life, and with lower self-reported time pressure. This study investigates some of the potential mechanisms behind these relationships.

METHODS

318 participants submitted their responses to an online survey which collected data regarding passage of time judgments, time pressure, trait mindfulness, temperament, task load, and metacognitions about time. Using commonality and dominance analyses, we explored how these variables contributed, either alone or jointly, to predicting how fast (or slow) time seems to pass for participants, or how pressed for time they felt.

RESULTS

Mindfulness and temperament had some overlaps in their ability to predict passage of time judgments and time pressure for durations at the month and 2-month scales. The temperamental trait of extraversion/surgency, as well as the Non-judging and Non-reacting facets of mindfulness were among the best predictors of passage of time judgments and time pressure. Attention-related variables were mainly related to time perception via their involvement in joint effects with other variables. Results also suggested that metacognitions about time interacted with other variables in predicting passage of time judgments, but only at the month scale. Finally, among all the variables included in this study, task load had the highest degree of involvement in predictions of self-reported time pressure at the week and month scales, but it contributed relatively little to predicting passage of time judgments.

CONCLUSIONS

Results suggest that mindfulness relates to passage of time through its involvement in inferential processes. The data also shows how different factors are related to PoTJ at different time scales. Finally, results suggest the existence of both similarities and differences in how passage of time and time pressure relate to the other included variables.

Changes in distinct brain systems identified with fMRI during smoking cessation treatment with varenicline: a review

BACKGROUND

Varenicline is considered one of the most effective treatment options for smoking cessation. Nonetheless, it is only modestly effective. A deeper comprehension of the effects of varenicline by means of the in-depth review of relevant fMRI studies may assist in paving the development of more targeted and effective treatments.

METHODOLOGY

A search of PubMed and Google Scholar databases was conducted with the keywords "functional magnetic resonance imaging" or "fMRI", and "varenicline". All peer-reviewed articles regarding the assessment of smokers with fMRI while undergoing treatment with varenicline and meeting the predefined criteria were included.

RESULTS

Several studies utilizing different methodologies and targeting different aspects of brain function were identified. During nicotine withdrawal, decreased mesocorticolimbic activity and increased amygdala activity, as well as elevated amygdala-insula and insula-default-mode-network functional connectivity are alleviated by varenicline under specific testing conditions. However, other nicotine withdrawal-induced changes, including the decreased reward responsivity of the ventral striatum, the bilateral dorsal striatum and the anterior cingulate cortex are not influenced by varenicline suggesting a task-dependent divergence in neurocircuitry activation. Under satiety, varenicline treatment is associated with diminished cue-induced activation of the ventral striatum and medial orbitofrontal cortex concomitant with reduced cravings; during the resting state, varenicline induces activation of the lateral orbitofrontal cortex and suppression of the right amygdala.

CONCLUSIONS

The current review provides important clues with regard to the neurobiological mechanism of action of varenicline and highlights promising research opportunities regarding the development of more selective and effective treatments and predictive biomarkers for treatment efficacy.

Learning to quit: can reinforcement theories predict the success of smoking cessation attempts using nicotine replacement therapy patches in a general population sample of smokers at 8-weeks and 6-months follow-up?

Primary, secondary, and tertiary reinforcement contribute to the maintenance of smoking behaviour and may influence the efficacy of different cessation treatments. This analysis examined these relationships in a large general population sample and investigated how previous experiences of the different reinforcement mechanisms impacted future quit attempts. Random digit telephone dialing was used to recruit a sample of Canadian adults who smoked and were interested in being part of a hypothetical program that would provide nicotine replacement therapy (NRT) patches free by mail and half of the eligible participants were randomized to actually receive a five-week supply of NRT patches. During the interviews, reasons for relapse to smoking during previous quit attempts were collected and coded by two reviewers (disagreements were settled by a third reviewer). Binary logistic regression was used to determine if type of reinforcer moderated the intervention effect of the patches. Participants who made cessation attempts in the past year were more likely to report negative (p = .039), secondary (p = .041), and tertiary (p = .010) reinforcers and less likely to report positive reinforcers (p = .016) compared to those who did not attempt to quit. Logistic regressions revealed no significant conditional effects of the intervention on the relationship between reinforcer type and quit attempts or 30-day smoking abstinence. Analysis including all three reinforcers showed negative reinforcers decreased but tertiary reinforcers increased the odds participants reported a cessation attempt before the baseline interview and between baseline and 8-weeks. Understanding the different ways nicotine reinforces smoking behaviour could help guide individuals to more effective treatment options.

Mindfulness interventions for craving reduction in substance use disorders and behavioral addictions: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

High-quality evidence is still required to affirm the efficacy of mindfulness-based interventions (MBIs) in craving reduction. MBIs may be particularly appropriate for this purpose given the neurobiological mechanisms of addiction with automatic behavior in response to the negative affect. In this systematic review and meta-analysis, we aimed to study the efficacy of MBIs in craving reduction and to synthetize the newly published data.

METHODS

We searched four databases and three clinical trial registries for randomized controlled trials (RCTs) up to August 2023, including studies with MBIs in all types of substance use disorders or behavioral addictions. We chose as our outcome of interest the change from the baseline of craving measures at posttreatment. Standardized mean difference was used as an effect size estimator.

RESULTS

We included 17 RCTs with 1228 participants. The overall effect size was estimated at -0.70 (95% CI -1.15, -0.26) in favor of MBIs.

CONCLUSION

Due to the high inconsistency (I2 = 92%), we were unable to conclude that there is a medium to large effect size. Overall risk of bias was high for most studies, and the GRADE approach detected a low quality of evidence. Previous clinical and fundamental research suggest that MBIs have a promising potential in addiction medicine. However, further investigation of whether MBIs effectively reduce craving is needed, and innovative solutions for resolving methodological limitations in MBI research are warranted.

TRIAL REGISTRATION

PROSPERO registration ID CRD42020221141.

Trait mindfulness weakens the relationship between Snapchat use and alcohol-related outcomes

Objective:Previous studies identified Snapchat as the most likely social media platform for depictions of excessive drinking and consequences. We sought to further examine this relationship and the possible protective impact of trait mindfulness.Method:A sample of 838 college students completed a survey assessing self-reported alcohol use, alcohol-related consequences, trait mindfulness, and individual and peer alcohol-related Snapchat posts.Results:Viewing more peer's Snapchats was associated with increased alcohol-related consequences, except at high levels of trait mindfulness. When controlling for the individual's Snapchat posts, the significant relationship between peer's Snapchats and consequences remained at low levels of trait mindfulness but not for moderate levels. The protective effect of high levels of trait mindfulness endured.Conclusion:Increasing trait mindfulness may help buffer the negative influence of viewing peer's alcohol-related Snapchats on alcohol-related consequences. Further examining how trait mindfulness interacts with peer norms offers important avenues for future research.

Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial

PURPOSE/OBJECTIVE

To examine the impact of three behavioral interventions for chronic pain on substance use.

RESEARCH METHOD/DESIGN

Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment.

RESULTS

Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up.

CONCLUSIONS/IMPLICATIONS

HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Network Analysis of Cigarette Craving

INTRODUCTION

Craving is considered a central process to addictive behavior including cigarette smoking, although the clinical utility of craving relies on how it is defined and measured. Network analysis enables examining the network structure of craving symptoms, identifying the most central symptoms of cigarette craving, and improving our understanding of craving and its measurement.

AIMS AND METHODS

This study used network analysis to identify the central symptoms of self-reported cigarette craving as measured by the Craving Experience Questionnaire, which assesses both craving strength and craving frequency. Data were obtained from baseline of a randomized controlled trial of mindfulness training for smoking cessation.

RESULTS

The most central symptoms in an overall cigarette craving network were the frequency of imagining its smell, imagining its taste, and intrusive thoughts. The most central symptoms of both craving frequency and craving strength sub-networks were imagining its taste, the urge to have it, and intrusive thoughts.

CONCLUSIONS

The most central craving symptoms reported by individuals in treatment for cigarette smoking were from the frequency domain, demonstrating the value of assessing craving frequency along with craving strength. Central craving symptoms included multisensory imagery (taste, smell), intrusive thoughts, and urge, providing additional evidence that these symptoms may be important to consider in craving measurement and intervention. Findings provide insight into the symptoms that are central to craving, contributing to a better understanding of cigarette cravings, and suggesting potential targets for clinical interventions.

IMPLICATIONS

This study used network analysis to identify central symptoms of cigarette craving. Both craving frequency and strength were assessed. The most central symptoms of cigarette craving were related to craving frequency. Central symptoms included multisensory imagery, intrusive thoughts, and urge. Central symptoms might be targeted by smoking cessation treatment.

COVID-19 Stress (Traumatic Symptoms, Compulsive Checking, Xenophobia, and Danger & Contamination) and Alcohol Use Uniquely Explain State Alcohol Cravings

Stressful events may lead to the consumption of alcohol as a self-medicating and coping strategy. The self-medication hypothesis and addiction loop model served as the theoretical frameworks to understand how various COVID-19 pandemic stressors serve as risks for alcohol usage and state alcohol cravings. The study hypothesized that higher COVID-19 stressors (past month) would predict higher alcohol use (past month), and both were hypothesized to uniquely explain stronger alcohol cravings (state). Adult alcohol users (N = 366) participated in this cross-sectional study. Respondents completed measures of the COVID Stress Scales (socioeconomic, xenophobia, traumatic symptoms, compulsive checking, and danger & contamination), drink frequency and drink quantity, and state alcohol cravings (Alcohol Urge Questionnaire and Desires for Alcohol Questionnaire). Results from a structural equation model involving latent factors determined that higher pandemic stress explained greater alcohol use, and both factors uniquely contributed to stronger state alcohol cravings. A structural equation model premised on specific measures revealed that higher xenophobia stress, higher traumatic symptoms stress, higher compulsive checking stress, and lower danger & contamination stress uniquely predicted drink quantity, but not drink frequency. Furthermore, greater drink quantity and drink frequency independently predicted stronger state alcohol cravings. The findings recognize that pandemic stressors operate as cue-induced triggers for alcohol use and cravings. The COVID-19 stressors identified in this study could be targeted in interventions based on the addiction loop model designed to mitigate the effects of stress cues on alcohol use and present cravings for alcohol.

App-Delivered Mindfulness Training to Reduce Anxiety in People with HIV Who Smoke: A One-Armed Feasibility Trial

INTRODUCTION

People with HIV (PWH) who smoke have reported that managing anxiety is a barrier to making a quit attempt and maintaining abstinence post-quit. This study examined the feasibility and acceptability of an app-based mindfulness intervention, Unwinding Anxiety, to reduce anxiety prior to a quit attempt in PWH who were not planning to quit in the next 30 days.

METHODS

Sixteen PWH (mean age 51.5 [SD = 13.2]; mean cigarettes per day 11.4 [SD = 5.4]) were enrolled and followed for eight weeks. A smartphone-based app with 30 modules designed to reduce anxiety was introduced at baseline; participants were encouraged to complete one module daily for four weeks. Symptoms of anxiety and readiness to quit smoking were measured at baseline and weeks 4 and 8. The mean number of modules completed, session attendance, and number of study completers were examined. Generalized estimating equations (GEE) were used to examine changes in self-reported anxiety and readiness to quit at baseline, week 4, and week 8. A brief qualitative interview was conducted at week 4 to explore the acceptability of the app.

RESULTS

Feasibility was high, with 93% of participants completing the study. The mean number of study sessions completed was 2.7 (SD = 0.59), and the mean number of modules completed was 16.0 (SD 16.8). Anxiety was high at baseline (M = 14.4, SD = 3.9), but lower at week 4 (b = -5.5; CI: [-9.4, -1.7]; p = 0.004) and week 8 (b = -5.1; CI: [-8.8, -1.3]; p = 0.008), and stable between weeks 4 and 8 (b = 0.48; CI: [-2.0, 3.0]; p = 0.706). Readiness to quit significantly increased from baseline M = 5.5 (SD = 1.6) to week 4 (b = 0.56; CI: [0.20, 0.91]; p = 0.002) but was not significantly different from baseline at week 8 (b = 0.34; CI: [-0.30, 1.0]; p = 0.30). Ad-hoc moderation analyses found that anxiety had a small significantly positive association with readiness to quit at baseline (main effect: b = 0.10; SE = 0.03; p < 0.001) and significantly attenuated the increase in readiness to quit observed at week 4 (anxiety by week 4 interaction: b = -0.08; SE = 0.03; p = 0.009).

CONCLUSIONS

App-based mindfulness training appears to be feasible and acceptable for PWH who smoke and report baseline anxiety. At week 4, anxiety was reduced and readiness to quit was increased, perhaps a key time point for a smoking cessation attempt.

Cluster-based psychological phenotyping and differences in anxiety treatment outcomes

The identification of markers of mental health illness treatment response and susceptibility using personalized medicine has been elusive. In the context of psychological treatment for anxiety, we conducted two studies to identify psychological phenotypes with distinct characteristics related to: psychological intervention modalities (mindfulness training/awareness), mechanism of action (worry), and clinical outcome (generalized anxiety disorder scale scores). We also examined whether phenotype membership interacted with treatment response (Study 1) and mental health illness diagnosis (Studies 1-2). Interoceptive awareness, emotional reactivity, worry, and anxiety were assessed at baseline in treatment-seeking individuals (Study 1, n = 63) and from the general population (Study 2, n = 14,010). In Study 1, participants were randomly assigned to an app-delivered mindfulness program for anxiety for two months or treatment as usual. Changes in anxiety were assessed 1 and 2 months post-treatment initiation. In studies 1-2, three phenotypes were identified: 'severely anxious with body/emotional awareness' (cluster 1), 'body/emotionally unaware' (cluster 2), and 'non-reactive and aware' (cluster 3). Study 1's results revealed a significant treatment response relative to controls (ps < 0.001) for clusters 1 and 3, but not for cluster 2. Chi-square analyses revealed that phenotypes exhibited significantly different proportions of participants with mental health diagnoses (studies 1-2). These results suggest that psychological phenotyping can bring the application of personalized medicine into clinical settings.Registry name and URL: Developing a novel digital therapeutic for the treatment of generalized anxiety disorder https://clinicaltrials.gov/ct2/show/NCT03683472?term=judson+brewer&draw=1&rank=1 .Trial registration: Registered at clinicaltrials.gov (NCT03683472) on 25/09/2018.

Examination of college student health behaviors and self-reported executive functions

Objective: Emerging adulthood is characterized by maturation of executive functions (EF) and changes in health behaviors (HB). Interestingly, EF are bi-directionally related to many specific HB; yet how EF performs in relation to overall patterns of HB engagement is unclear. Groupings of HB and the relationship between these HB groupings and EF were examined.

PARTICIPANTS

Full-time college students were recruited from three large Mid- and Southwest universities (N = 1,387).

METHODS

Online self-report questionnaires assessing demographics, HB, and EF were completed.

RESULTS

Latent class analysis of HB revealed three classes: (1) High Substance Use, (2) Moderately Healthy, (3) Healthy. In general, the Healthy class had significantly greater EF compared to no significant differences between the other two classes.

CONCLUSIONS

Collective engagement in HB is associated with EF. Interventions targeting both HB and EF simultaneously may be most efficacious.

A Just-In-Time Adaptive intervention (JITAI) for smoking cessation: Feasibility and acceptability findings

Smoking cessation treatments that are easily accessible and deliver intervention content at vulnerable moments (e.g., high negative affect) have great potential to impact tobacco abstinence. The current study examined the feasibility and acceptability of a multi-component Just-In-Time Adaptive Intervention (JITAI) for smoking cessation. Daily smokers interested in quitting were consented to participate in a 6-week cessation study. Visit 1 occurred 4 days pre-quit, Visit 2 was on the quit day, Visit 3 occurred 3 days post-quit, Visit 4 was 10 days post-quit, and Visit 5 was 28 days post-quit. During the first 2 weeks (Visits 1-4), the JITAI delivered brief mindfulness/motivational strategies via smartphone in real-time based on negative affect or smoking behavior detected by wearable sensors. Participants also attended 5 in-person visits, where brief cessation counseling (Visits 1-4) and nicotine replacement therapy (Visits 2-5) were provided. Outcomes were feasibility and acceptability; biochemically-confirmed abstinence was also measured. Participants (N = 43) were 58.1 % female (AgeMean = 49.1, mean cigarettes per day = 15.4). Retention through follow-up was high (83.7 %). For participants with available data (n = 38), 24 (63 %) met the benchmark for sensor wearing, among whom 16 (67 %) completed at least 60 % of strategies. Perceived ease of wearing sensors (Mean = 5.1 out of 6) and treatment satisfaction (Mean = 3.6 out of 4) were high. Biochemically-confirmed abstinence was 34 % at Visit 4 and 21 % at Visit 5. Overall, the feasibility of this novel multi-component intervention for smoking cessation was mixed but acceptability was high. Future studies with improved technology will decrease participant burden and better detect key intervention moments.

Cumulative exposure to traumatic events and craving among women in residential treatment for substance use disorder: The role of emotion dysregulation and mindfulness disposition

Objective

Strong evidence links exposure to traumatic life events with subsequent substance use disorders (SUD). Compared to men, women in SUD treatment are more likely to have a history of trauma, characterized in part by emotion dysregulation known to negatively influence treatment outcomes. Existing research has been conducted with predominantly male and non-Hispanic White samples, with an emphasis on adverse childhood experiences. Little is known about how exposure to cumulative traumatic events across the lifespan affects emotion dysregulation and how this may influence craving, particularly among racial and ethnic minoritized women with SUD. Mindfulness disposition may serve as a protective factor that could buffer the impact of trauma exposure and emotion dysregulation on substance use craving among underrepresented minoritized women with SUD. This study examined the association between cumulative exposure to traumatic events, emotion dysregulation, and mindfulness disposition on substance use craving in a sample of predominantly Hispanic and non-Hispanic Black women in residential treatment for SUD.

Method

Cross-sectional data were analyzed for a baseline sample of 241 women (56.96% Hispanic, 20.7% non-Hispanic White, 20.7% non-Hispanic Black; age: M = 32.11) entering a SUD residential treatment facility who agreed to participate in a parent randomized controlled trial.

Results

Findings indicated that greater cumulative exposure to traumatic events and emotion dysregulation were associated with higher levels of craving. Cumulative traumatic event exposure was indirectly associated with higher craving via lower levels in the mindfulness dimension of acting with awareness. Interaction effects also revealed greater exposure to traumatic events was associated with higher levels of craving among women with low and average (but not high) levels of mindfulness disposition.

Conclusion

These findings provide insight into the potential benefits of targeting emotion regulation and mindfulness-building strategies such as acting with awareness in interventions among racial-ethnically diverse women with SUD. These strategies may be particularly beneficial among those that have experienced extensive histories of trauma exposure. Overall, knowledge gained from the present study can be particularly valuable towards informing treatment models in minoritized groups that currently experience disparities in treatment utilization and outcomes.

What Happens When You Smoke a Cigarette Mindfully? A Deductive Qualitative Study

Objectives

The mindful smoking exercise instructs participants to pay attention to a range of experiences while smoking a cigarette with the expectation that it will modify the often automatic process of smoking. Given its theoretical value, mindfulness- and acceptance and commitment therapy-based smoking cessation interventions have usually included a mindful smoking exercise. However, its utility has not been empirically examined. Through qualitative analyses, the current study examined smokers' lived experience with mindful smoking during an 8-week telehealth group-based smoking cessation and alcohol modification trial.

Method

Participants were smokers who were present in group during the mindful smoking exercise. The recordings of sessions and follow-up interviews in which discussion on mindful smoking took place were transcribed and hand-coded for qualitative analysis. A thematic content analytic approach was used to identify themes.

Results

Participants (N=20) were 75% female (mean age=49.75, average cigarettes per day=16.35). Identified themes mapped onto both the theoretical rationale for mindful smoking (e.g., attention/awareness, decentering, similarity/difference between mindful versus automatic smoking) and cognitive-affective-behavioral responses (e.g., unpleasant/pleasant experience, shifts in desire to smoke, cognitive reappraisal). The most prominent themes were attention/awareness, similarity/difference between mindful versus automatic smoking, and unpleasant/pleasant experience; Dynamic interplay between themes was also observed and representative quotes are included.

Conclusions

Our findings indicate that intentionally paying attention to smoking led to the reporting of a heightened awareness of automatic behavior accompanied by noticing unpleasant aspects of smoking, potentially facilitating change in one's relationship to smoking. Theoretical implications of mindful smoking in the context of addiction are discussed.

Use and perceived usefulness of a just-in-time resonance breathing intervention adjunct for substance use disorder: Contextual and physiological predictors

Craving for alcohol and other drugs is often described as a momentary hyperarousal state that interferes with one's ability to use top-down strategies. As such, it may be best interrupted 'in the moment' through bottom-up modulation. We recently reported that episodic resonance paced breathing (eRPB) delivered via mobile phone app as an add-on to outpatient treatment for substance use disorder (SUD) was effective at dampening craving over the course of an 8-week intervention (NCT#02579317). However, not all participants engaged with the eRPB app and there was high intra- and inter-individual variability in weekly ratings of usefulness. Here we examined baseline demographic, physiological, and psychiatric measures as well as time-varying exposure to positive, negative, and temptation craving triggers as predictors of frequency of eRPB app use and ratings of usefulness. Seventy-seven outpatient women were randomized to an eRPB (0.1 Hz) or a faster paced breathing sham (0.23 Hz) condition. Baseline measures were assessed within the first 3 weeks of treatment entry prior to randomization. App use frequency, ratings of usefulness, and trigger exposure were measured weekly throughout the intervention. Variables were entered into marginal means models with forward stepwise model selection and examined as predictors of use and usefulness. Frequent app use was associated with a lifetime alcohol use disorder (AUD) diagnosis (p = 0.026), higher ratings of usefulness (p < 0.001), and fewer exposures to positive triggers (e.g., celebration, socialization; p < 0.001). There was a trend-level association between frequency of app use and greater cardiovascular capacity at baseline (p = 0.088). Higher ratings of usefulness were associated with greater exposure to negative triggers (e.g,. loneliness, frustration; p < 0.001) and parasympathetic dysregulation at baseline (p = 0.05). A positive relationship between app use frequency and ratings of usefulness was present only in the eRPB group (p = 0.045). Matching ideal candidates and moments to an arousal modulation anti-craving intervention can help streamline screening and implementation of eRPB in the treatment of SUD.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT02579317, identifier NCT02579317.

The Value of Contemplative Practices: A Mixed Methods Approach Exploring Associations between Resilience and Experiences of the COVID-19 Pandemic among Older Adults

The aim of this study was to explore the association between resilience and experiences of the COVID-19 pandemic among older adults. We used a sequential explanatory mixed methods study design to recruit older adults who spoke English and were 60 and above during the pandemic. Survey data investigated older adults' resilience, post-traumatic growth, well-being, and demographics. Extreme case purposeful sampling of their resilience score was used to select interviewees. Qualitative data sought to understand the relationship between resilience and how older adults responded to the COVID-19 pandemic. Exploring the relationship between resilience (well-being in the face of challenge) and one's experience of the COVID-19 pandemic revealed that participants categorized as having high resilience had long held behaviors of contemplative practices that helped them effectively adapt to the COVID-19 pandemic. As we continue to face global challenges, we must redefine care, guide interventions, and promote healthy aging by incorporating contemplative practices into the lives of older adults.

Mindfulness-Based Smoking Cessation Delivered Through Telehealth and Text Messaging for Low-Income Smokers: Protocol for a Randomized Controlled Trial

BACKGROUND

Tobacco use is the leading cause of preventable morbidity and mortality. Adults with low income and members of certain racial and ethnic minority groups are less likely to quit, and therefore, they experience profound tobacco-related health disparities. Mindfulness training can increase the rates of smoking cessation and lapse recovery, and telehealth and SMS text messaging have the potential to provide more accessible treatment.

OBJECTIVE

This study aims to test the efficacy of delivering mindfulness-based smoking cessation treatment through text messaging (iQuit Mindfully) and telehealth (group videoconferencing), both as stand-alone interventions and in combination. In addition, it aims to examine the underlying mechanisms of mindfulness treatment.

METHODS

In this 2×2 randomized controlled trial, participants are randomized into 1 of 4 groups based on assignment to iQuit Mindfully text messages (yes or no) and mindfulness videoconference groups (yes or no). The primary outcomes are biochemically verified smoking abstinence at 8, 12, and 24 weeks after the start of treatment. Secondary outcomes include the frequency of home mindfulness practice and self-reported levels of mindfulness, emotions, craving, withdrawal, dependence, self-efficacy, and social support.

RESULTS

Recruitment, treatment, and assessment began in spring and summer 2021, and data collection is expected to continue through spring 2024.

CONCLUSIONS

This project aims to improve smoking cessation outcomes for low-income, racially and ethnically diverse smokers through mindfulness-based telehealth group counseling and text messaging support. We also aim to advance the scientific study of the mechanisms of action of mindfulness treatment, which could inform the development of more efficacious and efficient treatments to reduce tobacco disparities.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04965181; https://clinicaltrials.gov/ct2/show/NCT04965181.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/35688.

App-Based Mindfulness Training Predicts Reductions in Smoking Behavior by Engaging Reinforcement Learning Mechanisms: A Preliminary Naturalistic Single-Arm Study

Mindfulness training (MT) has been shown to influence smoking behavior, yet the involvement of reinforcement learning processes as underlying mechanisms remains unclear. This naturalistic, single-arm study aimed to examine slope trajectories of smoking behavior across uses of our app-based MT craving tool for smoking cessation, and whether this relationship would be mediated by the attenuating impact of MT on expected reward values of smoking. Our craving tool embedded in our MT app-based smoking cessation program was used by 108 participants upon the experience of cigarette cravings in real-world contexts. Each use of the tool involved mindful awareness to the experience of cigarette craving, a decision as to whether the participant wanted to smoke or ride out their craving with a mindfulness exercise, and paying mindful attention to the choice behavior and its outcome (contentment levels felt from engaging in the behavior). Expected reward values were computed using contentment levels experienced from the choice behavior as the reward signal in a Rescorla−Wagner reinforcement learning model. Multi-level mediation analysis revealed a significant decreasing trajectory of smoking frequency across MT craving tool uses and that this relationship was mediated by the negative relationship between MT and expected reward values (all ps < 0.001). After controlling for the mediator, the predictive relationship between MT and smoking was no longer significant (p < 0.001 before and p = 0.357 after controlling for the mediator). Results indicate that the use of our app-based MT craving tool is associated with negative slope trajectories of smoking behavior across uses, mediated by reward learning mechanisms. This single-arm naturalistic study provides preliminary support for further RCT studies examining the involvement of reward learning mechanisms underlying app-based mindfulness training for smoking cessation.

What Next After MBSR/MBCT? An Open Trial of an 8-Week Follow-on Program Exploring Mindfulness of Feeling Tone (vedanā)

Objectives

The effectiveness of mindfulness-based programs (MBPs) has been established in many randomized controlled trials. However, effect sizes are often modest, and there remains ample scope to improve their effectiveness. One approach to this challenge is to offer a “follow-on” course to people who have completed an MBP and are interested in further skill development. We developed and tested a new 8-week course for this purpose based on awareness of feeling tone (vedanā), an understudied aspect of mindfulness in many current MBPs, incorporating new developments in neuroscience and trauma sensitivity. We examined its effectiveness and the frequency and severity of unpleasant experience and harm.

Methods

In an open trial, 83 participants, 78 of whom had previously taken part in an MBP (majority MBSR or MBCT), completed the program in nine groups. Participants completed questionnaires before and after and gave qualitative written feedback at completion.

Results

Participants reported significantly reduced depression (d = 0.56), stress (d = 0.36), and anxiety (d = 0.53) and increased well-being (d = 0.54) and mindfulness (d = 0.65) with 38% meeting criteria for reliable change on anxiety and depression. As expected, about three-quarters of participants reported some unpleasant experiences associated with mindfulness practice during the course, but none reported harm. Five participants showed “reliable deterioration” (an increase) in either depression or anxiety, but four of these five also gave anonymous qualitative feedback describing benefits of the course.

Conclusions

Findings support the added value of a follow-on course based on the exploration of feeling tone for participants who have a range of previous mindfulness experience.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12671-022-01929-0.

EcoMeditation Modifies Brain Resting State Network Activity

Background

The tendency of the mind to wander, a characteristic of the brain's default mode network (DMN), correlates with increased unhappiness and self-referential processing and is a deterrent to establishing a consistent meditation practice. The objective of this study was to test the impact of a secular physiological method of meditation. We hypothesized that EcoMeditation would produce increases in neural communication in brain regions associated with compassion and prosociality and decreases in self-referencing networks, such as the DMN, and that these changes would be found in the experimental group, but not the control group.

Methods

Participants (n=38) were randomized into two groups, and the final sample consisted of 25 participants. One group listened daily to a 22-minute EcoMeditation audio track, while the other used an active control. Functional magnetic resonance imaging (fMRI) was used to assess brain function before and after four weeks of practice. Mystical experiences, as well as psychological conditions, such as anxiety and depression, were measured.

Results

Participants in the EcoMeditation group showed significantly increased connectivity between the bilateral hippocampus and the bilateral insula, compared to pre-intervention. In addition, significant decreases of connectivity between the bilateral hippocampus and the midprefrontal and left dorsolateral prefrontal cortices occurred. EcoMeditation participants also scored significantly higher for mystical experiences than the control group. The results for emotional states were mixed, with one assessment finding increased positive mood, but another finding increased negative affect.

Conclusion

After only four weeks, participants using EcoMeditation demonstrated brain states similar to meditation adepts with thousands of hours of traditional practice.

Need for mindfulness-based relapse prevention strategies for postpartum smoking relapse prevention

The health concerns for women are varied from that of men and are of higher concern. To increase this concern, women have recorded higher smoking relapse rates than men were an alarming 60% to 90% of the women who have attempted to quit relapse within their first year. Women who quit during pregnancy are seen to have higher rates of relapse than others. Such postpartum relapse has detrimental effects on the mother as well as the newborn. Mindfulness-based interventions have seen benefits in the areas of substance abuse and relapse prevention. Although research in the area of mindfulness and its benefits on smoking cessation has been limited, literature shows positive outcomes. This brief article examines the need for mindfulness-based relapse prevention strategies for women who are undergoing postpartum smoking relapses so that they could benefit from the same.

Mindfulness as a Protective Factor Against Increased Tobacco and Alcohol Use in Hospital Workers Following the First COVID-19-Related Lockdown: a Study in Southern France

COVID-19-related national lockdowns worldwide have had repercussions on people's well-being and have led to increased substance use. Mindfulness has previously been associated with reduced psychological distress and benefits in terms of addictive behaviors. We aimed to assess whether dispositional mindfulness protected against increased tobacco and alcohol use in hospital workers after France's first lockdown started. All workers in two French hospitals were contacted by email to participate in an online survey. Three hundred eighty-five workers answered. We ran two separate logistic regression models to test for associations between the level of dispositional mindfulness and both increased tobacco and alcohol use, after adjusting for affect deterioration. Dispositional mindfulness was associated with a lower likelihood of increased tobacco (adjusted odds ratio (AOR) [95% CI] 0.71 [0.51; 0.99], p = 0.046) and alcohol (0.66 [0.50; 0.87], p = 0.004) use. The effect of mindfulness on tobacco use was partially mediated by affect deterioration. Dispositional mindfulness appeared to be a protective factor against lockdown-related tobacco and alcohol use increases in French hospital workers.

Mindfulness and Mobile Health for Quitting Smoking: A Qualitative Study Among Predominantly African American Adults with Low Socioeconomic Status

Low-income and African American adults experience severe tobacco-related health disparities. Mindfulness-based interventions show promise for promoting smoking cessation, but most mindfulness research has focused on higher income, Caucasian samples. "iQuit Mindfully" is a personalized, interactive text messaging program that teaches mindfulness for smoking cessation. This qualitative study sought feedback from predominantly low-income African American smokers, to improve the intervention for this priority population. After receiving 8 weekly group sessions of Mindfulness-Based Addiction Treatment for smoking cessation and between-session iQuit Mindfully text messages, participants (N=32) completed semi-structured interviews. Participants were adult cigarette smokers (90.6% African American, 62.6% annual income <$30,000, mean age 45.1 [±12.9]). Interviews inquired about participants' experiences with and suggestions for improving iQuit Mindfully, including message content, number, and timing. Interviews were audio-recorded, transcribed verbatim, and coded by a team of 5 coders in NVivo. The coding manual was developed based on response categories from the interview guide and themes emerging from the data. Themes were organized into a conceptual model of factors related to engagement with the mHealth program. Response categories included helpful aspects (e.g., themes of social support, mindfulness, personalization); unhelpful/disliked aspects (e.g., too many/repetitive messages); links between in-person sessions and texts; and suggestions (e.g., changes to number/timing and more personalization). Findings provide insight into participants' day-to-day experiences with iQuit Mindfully and suggest ways to improve mHealth programs among low-income and African American adults.

Associations between COVID-19 risk perceptions and smoking and quitting behavior among U.S. adults

•

Smokers are more likely to think smoking increases risk of COVID-19 severity than susceptibility.

•

Perceiving risk of COVID-19 severity is associated with readiness to quit and quit attempts.

•

Perceiving risk of COVID-19 severity is also linked with both smoking increases and decreases.

•

Greater psychological distress is associated with changes in smoking and quitting behavior.

Objectives

The COVID-19 pandemic may impact cigarette smokers’ behaviors. Among smokers, perceptions about the risks of contracting COVID-19 and the severity of COVID-19 illness likely vary, and perceptions may be associated with individual smoking behavior. Our study measured smokers’ perceptions of COVID-19 risks and their association with smoking and quitting outcomes.

Methods

A sample of 1,223 U.S. adult cigarette smokers participated in an online survey in October-November 2020 to assess their COVID-19-related risk perceptions and changes in smoking, readiness to quit, and quit attempts during the COVID-19 pandemic.

Results

More smokers believed smoking could increase the severity of COVID-19 (43.6%, 95% CI: 40.1, 47.3) than believed smoking makes them more susceptible to COVID-19 (20.0%, 95% CI: 17.2, 23.0.). While there were no associations between perceptions of COVID-19 susceptibility and smoking behaviors or intentions, perceptions of greater smoking-related COVID-19 severity were associated with both higher likelihood of smoking increases (aOR: 2.16, 95% CI: 1.19, 3.93) and greater readiness to quit smoking (aOR: 1.65, 95% CI: 1.18, 2.30). Greater perceptions of general COVID-19 severity were associated with higher likelihood of smoking reductions (aOR: 1.12, 95% CI: 1.02, 1.22), greater readiness to quit smoking (aOR: 1.14, 95% CI: 1.07, 1.22), and higher likelihood of making a quit attempt (aOR: 1.12, 95% CI: 1.04, 1.22).

Conclusions

Smokers’ perceptions about COVID-19 severity are related to their smoking behavior and likelihood of making a quit attempt. Providing smokers with accurate information on the relationship between smoking and the severity of COVID-19 may alter smoking behaviors.

Clinical Efficacy and Psychological Mechanisms of an App-Based Digital Therapeutic for Generalized Anxiety Disorder: Randomized Controlled Trial

Background

Current treatments for generalized anxiety disorder (GAD) often yield suboptimal outcomes, partly because of insufficient targeting of underlying psychological mechanisms (eg, avoidance reinforcement learning). Mindfulness training (MT) has shown efficacy for anxiety; yet, widespread adoption has been limited, partly because of the difficulty in scaling in-person–based delivery. Digital therapeutics are emerging as potentially viable treatments; however, very few have been empirically validated.

Objective

The aim of this study is to test the efficacy and mechanism of an app-delivered MT that was designed to target a potential mechanism of anxiety (reinforcement learning), based on which previous studies have shown concern regarding feedback and the perpetuation of anxiety through negative reinforcement.

Methods

Individuals with GAD were recruited using social media advertisements and randomized during an in-person visit to receive treatment as usual (n=33) or treatment as usual+app−delivered MT (Unwinding Anxiety; n=32). The latter was composed of 30 modules to be completed over a 2-month period. Associated changes in outcomes were assessed using self-report questionnaires 1 and 2 months after treatment initiation.

Results

We randomized 65 participants in this study, and a modified intent-to-treat approach was used for analysis. The median number of modules completed by the MT group was 25.5 (IQR 17) out of 30; 46% (13/28) of the participants completed the program. In addition, the MT group demonstrated a significant reduction in anxiety (GAD-7) compared with the control group at 2 months (67% vs 14%; median change in GAD-7: –8.5 [IQR 6.5] vs –1.0 [IQR 5.0]; P<.001; 95% CI 6-10). Increases in mindfulness at 1 month (nonreactivity subscale) mediated decreases in worry at 2 months (Penn State Worry Questionnaire; P=.02) and decreases in worry at 1 month mediated reductions in anxiety at 2 months (P=.03).

Conclusions

To our knowledge, this is the first report on the efficacy and mechanism of an app-delivered MT for GAD. These findings demonstrate the clinical efficacy of MT as a digital therapeutic for individuals with anxiety (number needed to treat=1.6). These results also link recent advances in our mechanistic understanding of anxiety with treatment development, showing that app-delivered MT targets key reinforcement learning pathways, resulting in tangible, clinically meaningful reductions in worry and anxiety. Evidence-based, mechanistically targeted digital therapeutics have the potential to improve health at a population level at a low cost.

Trial Registration

ClinicalTrials.gov NCT03683472; https://clinicaltrials.gov/ct2/show/NCT03683472

Smartband-Based Automatic Smoking Detection and Real-time Mindfulness Intervention: Protocol for a Feasibility Trial

Background

Smoking is the leading cause of preventable death in the United States. Smoking cessation interventions delivered by smartphone apps are a promising tool for helping smokers quit. However, currently available smartphone apps for smoking cessation have not exploited their unique potential advantages to aid quitting. Notably, few to no available apps use wearable technologies, most apps require users to self-report their smoking, and few to no apps deliver treatment automatically contingent upon smoking.

Objective

This pilot trial tests the feasibility of using a smartband and smartphone to monitor and detect smoking and deliver brief mindfulness interventions in real time to reduce smoking.

Methods

Daily smokers (N=100, ≥5 cigarettes per day) wear a smartband for 60 days to monitor and detect smoking, notify them about their smoking events in real time, and deliver real-time brief mindfulness exercises triggered by detected smoking events or targeted at predicted smoking events. Smokers set a quit date at 30 days. A three-step intervention to reduce smoking is tested. First, participants wear a smartband to monitor and detect smoking, and notify them of smoking events in real time to bring awareness to smoking and triggers for 21 days. Next, a “mindful smoking” exercise is triggered by detected smoking events to bring a clear recognition of the actual effects of smoking for 7 days. Finally, after their quit date, a “RAIN” (recognize, allow, investigate, nonidentification) exercise is delivered to predicted smoking events (based on the initial 3 weeks of tracking smoking data) to help smokers learn to work mindfully with cravings rather than smoke for 30 days. The primary outcomes are feasibility measures of treatment fidelity, adherence, and acceptability. The secondary outcomes are smoking rates at end of treatment.

Results

Recruitment for this trial started in May 2021 and will continue until November 2021 or until enrollment is completed. Data monitoring and management are ongoing for enrolled participants. The final 60-day end of treatment data is anticipated in January 2022. We expect that all trial results will be available in April 2022.

Conclusions

Findings will provide data and information on the feasibility of using a smartband and smartphone to monitor and detect smoking and deliver real-time brief mindfulness interventions, and whether the intervention warrants additional testing for smoking cessation.

Trial Registration

ClinicalTrials.gov NCT03995225; https://clinicaltrials.gov/ct2/show/NCT03995225

International Registered Report Identifier (IRRID)

DERR1-10.2196/32521

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

Mindfulness-based interventions for eating disorders: The potential to mobilize multiple associative-learning change mechanisms

Mindfulness is a two-component skill that includes mindful awareness (attentional monitoring of present moment experience) and mindful acceptance (adopting an attitude of acceptance toward this experience). Although mindfulness-based interventions (MBIs) are efficacious for many conditions, there is a lack of research on MBIs for eating disorders (EDs). We propose that MBIs may be promising for EDs given their potential to mobilize not one, but multiple associative-learning change mechanisms in EDs-defined as adaptive processes of change involving one of two forms of associative-learning: Pavlovian and operant learning. We hypothesize how MBIs-via increasing either mindful awareness or mindful acceptance-may mobilize up to eight associative-learning change mechanisms, two involving Pavlovian learning, and six involving operant learning. We also elaborate on similarities and differences between MBIs and CBT approaches for EDs, as well as opportunities for synergy. Finally, we present recommendations for future research related to the development and evaluation of novel MBI interventions for EDs and the testing of mechanisms and patient-treatment matching hypotheses.

Can Approaching Anxiety Like a Habit Lead to Novel Treatments?

Anxiety disorders make up the most prevalent class of mental illnesses. Given the growing prevalence of anxiety in the United States and beyond, there is an urgent clinical need to develop nonpharmacologic treatments that effectively treat and reduce its core symptoms (eg, worry). A leading theory posits that although worrying may be unpleasant, the immediate emotions that are avoided by concentrating on worry are often perceived as more aversive (eg, fear, anger, grief). From a mechanistic perspective, worry is thought to be learned and reinforced in a similar manner to other types of positively and negatively reinforced behaviors: habits. Mindfulness training, a practice that brings awareness to cognitive, affective, and physiological experiences, when delivered in-person via programs such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), has demonstrated effectiveness in reducing anxiety, but is difficult to scale in this manner. In this review, we explore novel approaches to using mindfulness training to specifically target the theoretical mechanisms underlying the perpetuation of anxiety (eg, worry as a habit), and the emergence of mobile health platforms (eg, digital therapeutics) as potential vehicles for remote delivery of treatment.

Mobile Delivery of Mindfulness-Based Smoking Cessation Treatment Among Low-Income Adults During the COVID-19 Pandemic: Pilot Randomized Controlled Trial

BACKGROUND

Smoking is the leading cause of premature death, and low-income adults experience disproportionate burden from tobacco. Mindfulness interventions show promise for improving smoking cessation. A text messaging program "iQuit Mindfully" was developed to deliver just-in-time support for quitting smoking among low-income adults. A pilot study of iQuit Mindfully was conducted in spring 2020, during the COVID-19 pandemic, among low-income and predominantly African American smokers.

OBJECTIVE

This pilot study examined the acceptability and feasibility of delivering Mindfulness-Based Addiction Treatment via mHealth during the COVID-19 pandemic.

METHODS

Participants were adult cigarette smokers (n=23), of whom 8 (34.8%) were female, 19 (82.6%) were African American, and 18 (78.3%) had an annual income of <US $24,000. They were randomly assigned to either 8 weeks of iQuit Mindfully as a fully automated standalone intervention or iQuit Mindfully in combination with therapist-led in-person group treatment. For participant safety, in-person mindfulness groups were transitioned to the internet and assessments also took place over the internet. Survey questions asked participants about changes in their stress, smoking habits and quit attempts, and their perceptions of the mindfulness and text messaging intervention in the context of the pandemic.

RESULTS

Most participants (n=15 of 21, 71.4%) indicated a change in stress due to the pandemic, of whom 14 (93.3%) indicated higher stress. Participants shared concerns about finances, homelessness, health, and social isolation. Most (n=17 of 21, 80.9%) believed that smoking increases the risk of contracting COVID-19, and although that was motivating for some, others expressed lower motivation to quit smoking because of higher stress. Most (n=18 of 21, 85.7%) stated that practicing mindfulness was helpful during the pandemic. Mean ratings of the helpfulness of text messages and the extent to which they would recommend the program to others were 7.1 (median 8 on a 10-point scale, SD 2.9) and 8.2 (median 9, SD 2.5), respectively. Through open-ended program evaluations, participants shared details about how mindfulness practices and the text messages helped them manage stress and feel a sense of social support during the pandemic. Moreover, 10 of 19 (52.6%) of participants achieved 7-day abstinence from smoking, with no differences between conditions.

CONCLUSIONS

This study supports the promise of text messaging and the use of teleconferencing to provide mindfulness and smoking cessation services to underserved populations during a pandemic.

Reach versus effectiveness: The design and protocol of randomized clinical trial testing a smartphone application versus in-person mindfulness-based smoking cessation intervention among young cancer survivors

Approximately 45% of young cancer survivors (18-40 years) are cigarette smokers. Continued smoking after cancer diagnosis leads to lower survival rates. A major logistical problem with smoking cessation efforts in this group is their geographic dispersion which makes them hard to reach. In addition, depression is a major predictor of smoking relapse and its rates are roughly twice as high in cancer survivors as the general population. Smartphone applications (apps) show promise in terms of efficacy, dissemination, and improving access to treatment. Mindfulness training (defined as maintaining attention on one's immediate experience and cultivating an attitude of acceptance toward this experience) is effective in improving smoking cessation outcomes by reducing psychological stress and controlling craving. Given that smartphone apps can address the issues of mobility and remote access, and mindfulness can address the high depression rate among cancer survivors, validating the feasibility and efficacy of a mindfulness-based smoking cessation intervention app in young cancer survivors is a high priority. Thus, the aims of the current study are: (1) test the feasibility, acceptability, and potential efficacy of the mindfulness-based smoking cessation app versus in-person mindfulness or usual care in a 3-arm pilot randomized clinical trial among young cancer survivors (n = 60; 18-40 years); and 2) conduct semi-structured exit interviews with participants in the two mindfulness groups to fine-tune the two active interventions based on feedback from participants. Findings will have implications for the development and dissemination of innovative and highly scalable tobacco cessation interventions designed for young cancer survivors.

Coping With COVID-19: Mindfulness-Based Approaches for Mitigating Mental Health Crisis

The novel coronavirus disease COVID-19 that first emerged in Wuhan, China, in Nov-Dec 2019 has already impacted a significant proportion of the world population. Governments of many countries imposed quarantines and social distancing measures in 2020, many of which remain in place, to mitigate the spread of the SARS-Cov-2 virus causing the COVID-19 disease. The direct impact of COVID-19 on people infected with the virus, their families and the health care workers, as well as the impact of the mitigation measures such as quarantine, social distancing, and self-isolation on the rest of the population have contributed to a global mental health pandemic, including anxiety, depression, panic attacks, posttraumatic stress symptoms, psychosis, addiction, obsessive-compulsive disorder, and suicidality. These effects are present acutely (for example, due to fear of contamination or losing loved ones, effects of quarantine/isolation, withdrawal of community and social services, etc.) and may continue long after the pandemic is over (for example, due to bereavement, unemployment, financial losses, etc). The COVID-19 pandemic has triggered mental health problems in people without previous history of mental illness, as well as worsened the symptoms in those with pre-existing psychiatric diagnosis. Therefore, the global effort is called for to deal with this mental health pandemic secondary to COVID-19 itself to address the emergence of new as well as the exacerbation of the existing mental health issues. Conversely, this global context provides an extraordinary opportunity for studying individual differences in response to and resilience in the face of physical and psychological threat, challenge to "normal" way of life, and long-term uncertainty. In this viewpoint article we outline the particular suitability of mindfulness, its skills and mechanisms, as an approach to the prevention and management of mental health issues, as well as to the promotion of well-being and building the foundations of adaptability and flexibility in dealing with the long-term uncertainty and profound changes to the social, economic, and possibly political systems as this pandemic continues to unfold.

Implementation of a Smoking Cessation e-Learning Education Program for Oncology Clinic Healthcare Providers: Evaluation With Implications for Evidence-Based Practice

BACKGROUND

Continued smoking after a cancer diagnosis increases the risk for treatment complications, primary cancer recurrence, and secondary malignancy development, while also reducing treatment efficacy, survival, and overall health. The lack of formal evidence-based smoking cessation education programs for oncology healthcare providers is a barrier to smoking cessation practices.

PURPOSE

To evaluate the use of an evidence-based, smoking cessation e-learning education program for oncology healthcare providers.

METHODS

A single group, pre- and post-test, nonexperimental design was used in this evidence-based quality improvement project. To assess the provider's knowledge in smoking cessation, a baseline assessment, a post-test, and an online survey were completed by the providers. A telephone survey was conducted to assess the patients' perception of cessation services received.

RESULTS

The healthcare providers' (N = 58) test scores on smoking cessation knowledge increased significantly (p < .0001) after completing the e-learning education program. A majority of the providers reported that the education program increased their confidence (86%) in successfully helping the patient to quit smoking and agreed to make smoking cessation a priority (89%) in their practice. A majority of the patients (85%) were satisfied or extremely satisfied with the smoking cessation services received. Many patients (71%) self-reported having tried to quit smoking.

CONCLUSION

An evidence-based e-learning education program is effective in increasing oncology healthcare providers' knowledge and confidence in tobacco dependence treatment practices. The program also has a positive impact on oncology patients' perception of cessation services received.

LINKING EVIDENCE TO ACTION

A self-paced e-learning program is a feasible and effective way to educate healthcare providers in smoking cessation treatment. Incorporating evidence-based tobacco dependence treatment into their daily oncology practice is warranted.

Craving to Quit: A Randomized Controlled Trial of Smartphone App-Based Mindfulness Training for Smoking Cessation

INTRODUCTION

Mindfulness training may reduce smoking rates and lessen the association between craving and smoking. This trial tested the efficacy of mindfulness training via smartphone app to reduce smoking. Experience sampling (ES) was used to measure real-time craving, smoking, and mindfulness.

METHODS

A researcher-blind, parallel randomized controlled trial compared the efficacy of mobile mindfulness training with experience sampling (MMT-ES; Craving to Quit) versus experience sampling only (ES) to (1) increase 1-week point-prevalence abstinence rates at 6 months, and (2) lessen the association between craving and smoking. A modified intent-to-treat approach was used for treatment starters (MMT-ES n = 143; ES n = 182; 72% female, 81% white, age 41 ± 12 year).

RESULTS

No group difference was found in smoking abstinence at 6 months (overall, 11.1%; MMT-ES, 9.8%; ES, 12.1%; χ2(1) = 0.43, p = .51). From baseline to 6 months, both groups showed a reduction in cigarettes per day (p < .0001), craving strength (p < .0001) and frequency (p < .0001), and an increase in mindfulness (p < .05). Using ES data, a craving by group interaction was observed (F(1,3785) = 3.71, p = .05) driven by a stronger positive association between craving and cigarettes per day for ES (t = 4.96, p < .0001) versus MMT-ES (t = 2.03, p = .04). Within MMT-ES, the relationship between craving and cigarettes per day decreased as treatment completion increased (F(1,104) = 4.44, p = .04).

CONCLUSIONS

Although mindfulness training via smartphone app did not lead to reduced smoking rates compared with control, our findings provide preliminary evidence that mindfulness training via smartphone app may help lessen the association between craving and smoking, an effect that may be meaningful to support quitting in the longer term.

IMPLICATIONS

This is the first reported full-scale randomized controlled trial of any smartphone app for smoking cessation. Findings provide preliminary evidence that smartphone app-based MMT-ES may lessen the association between craving and smoking.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02134509.

Self-Regulation Without Force: Can Awareness Leverage Reward to Drive Behavior Change?

To reach longer-term goals and live aligned with their values, people typically must regulate their behavior. Effortful self-control is one way to achieve this and is usually framed as a forceful struggle between lower-level impulses and higher-level cognitive control processes. For example, people may restrain themselves from eating cake in order to lose weight. An alternative avenue of self-regulation draws on autonomous motivation: Individuals eat healthfully because it is values-congruent or intrinsically satisfying. Recent advances in the understanding of reward valuation on a neural level (e.g., ventromedial prefrontal cortex/orbitofrontal cortex) and emerging treatments on a clinical level (e.g., mindfulness training) suggest a possible mechanistic convergence between brain and behavior that is consistent with a shift from forced to unforced behavior change. Here we propose how an overlooked aspect of reinforcement learning can be leveraged using a simple yet critical feature of experience that is not reliant on willpower: Bringing awareness to one's subjective experience and behavior can produce a change in valuation of learned but unhealthy behaviors, leading to self-regulatory shifts that result in sustainable behavior change without force.

Effectiveness of Mindfulness-Based Relapse Prevention Program as an Adjunct to the Standard Treatment for Smoking: A Pragmatic Design Pilot Study

INTRODUCTION

Posttreatment relapse is a major roadblock to stemming the global epidemic of tobacco-related illness. This article presents results from a pilot trial evaluating the feasibility and initial efficacy of Mindfulness-Based Relapse Prevention (MBRP) as an adjunct to standard relapse prevention treatment (ST) for smoking cessation.

AIMS AND METHODS

Smokers (n = 86) in the maintenance phase of treatment were randomized to receive either ST plus MBRP (MBRP) (n = 44) or ST alone (ST) (n = 42). Data were collected at baseline and at 4-, 12-, and 24-week follow-up points. We evaluated the feasibility of the protocol with frequency analysis, and the efficacy with both intention to treat and complete case analyses of the effects of MBRP on abstinence. Secondary outcomes included mindfulness, craving, depression, anxiety, and positive/negative affect.

RESULTS

High adherence suggested MBRP is acceptable and feasible. Participants in the MBRP group reported increases in mindfulness (M = -7.833, p = .016), and reductions in craving (M = 17.583, p = .01) compared with the ST group. Intention to treat analysis found that, compared with MBRP (36.4%), ST (57.1%) showed trend-level superiority in abstinence at Week 4 (Prevalence Ratio = 0.63, p = .06); however at Week 24, the ST group (14.3%) demonstrated a twofold greater decrease in abstinence, compared with the MBRP group (20.1%) (Prevalence Ratio = 2.25, p = .08). Therefore, the MBRP group maintained a higher abstinence rate for longer. Reported effects were greater in the complete case analysis.

CONCLUSIONS

MBRP holds promise for preventing relapse after aided tobacco quit attempts.

IMPLICATIONS

Findings suggest that MBRP is acceptable, feasible, and valued by participants. At 24-week follow-up, there was a large effect size and a statistical trend toward fewer MBRP patients relapsing compared with ST patients. MBRP conferred ancillary benefits including reductions in craving and increases in levels of mindfulness. MBRP for tobacco cessation is highly promising and merits further research.

TRIAL REGISTRATION

clinicaltrials.gov.

IDENTIFIER

NCT02327104.

Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence

BACKGROUND

Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness of digital interventions for tobacco cessation.

OBJECTIVE

This study aimed to evaluate participant adherence and smoking cessation outcomes in a pilot randomized controlled trial of the digital intervention Mindcotine (MindCotine Inc) using a self-administered treatment of virtual reality combined with mindfulness.

METHODS

A sample of 120 participants was recruited in the city of Buenos Aires, Argentina (mean age 43.20 years, SD 9.50; 57/120, 47.5% female). Participants were randomly assigned to a treatment group (TG), which received a self-assisted 21-day program based on virtual reality mindful exposure therapy (VR-MET) sessions, daily surveys, and online peer-to-peer support moderated by psychologists, or a control group (CG), which received the online version of the smoking cessation manual from the Argentine Ministry of Health. Follow-up assessments were conducted by online surveys at postintervention and 90-day follow-up. The primary outcome was self-reported abstinence at postintervention, with missing data assumed as still smoking. Secondary outcomes included sustained abstinence at 90-day follow-up, adherence to the program, and readiness to quit.

RESULTS

Follow-up rates at day 1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At postintervention, the TG reported 23% (14/60) abstinence on that day compared with 5% (3/60) in the CG. This difference was statistically significant (χ²₁=8.3; P=.004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Since only 20% (12/60) of participants in the CG completed the 90-day follow-up, we did not conduct a statistical comparison between groups at this follow-up time point. Among participants still smoking at postintervention, the TG was significantly more ready to quit compared to the CG (TG: mean 7.71, SD 0.13; CG: mean 7.16, SD 0.13; P=.005). A total of 41% (23/56) of participants completed the treatment in the time frame recommended by the program.

CONCLUSIONS

Results provide initial support for participant adherence to and efficacy of Mindcotine and warrant testing the intervention in a fully powered randomized trial. However, feasibility of trial follow-up assessment procedures for control group participants needs to be improved. Further research is needed on the impact of VR-MET on long-term outcomes.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN50586181; http://www.isrctn.com/ISRCTN50586181.

Directing Technology Addiction Research in Information Systems

Technology-related addictions have become common in many societies. Consequently, IS research has started examining such issues. In these embryonic stages of research, this line of work has already shown some promise in terms of understanding and tackling technology addiction problems. Nevertheless, there is a need to step back and understand the roots of technology-related addictions and how their foundations evolved in reference disciplines in order to be able to conduct more scientifically informed research on such issues. This study, therefore, explains the concept of behavioral addictions (the family of addictions to which technology-related addictions presumably belong), reviews the field's history and evolution, explains the relevant brain circuitry, and discusses similarities and differences between behavioral and substance addictions. A synthesis of this information provides eight key observations and recommendations that should help the field move forward.

Women's Experiences with a Mindful Eating Program for Binge and Emotional Eating: A Qualitative Investigation into the Process of Change

Objectives: Mindfulness-based interventions (MBIs) have been shown to reduce engagement in disordered eating behaviors, although how these interventions engender change remains unclear. The objective of this exploratory qualitative study was to describe the experiences and perceived attitudinal and behavioral changes of women participating in a mindful eating program. Design: Focus group discussions were held with women participating in a community-based mindful eating program for binge and emotional eating. A semistructured interview guide was used to explore participants' conceptualizations of mindfulness-based attitudinal and behavior change, as related to food, eating, and body image. The focus group discussions were audio-recorded, transcribed, and analyzed using thematic analysis to identify salient concepts. Settings/Location: Focus group discussions were held at the Center for Mindfulness at the University of Massachusetts Medical School (UMMS) (United States). Participants: A sample of nine women who were enrolled in the mindful eating program at UMMS for problems with self-reported binge and/or emotional eating participated in this study. Results: Four themes were constructed that described a process of mindfulness-based behavior change, including (1) Learning Through Self-Awareness, (2) Self-Empowerment, (3) Mindful Choice-Making, and (4) Resilient Self-Care. An overarching description of the participants' perceived attitudinal and behavior changes was developed: "unforced freedom of choice, emerging from embodied awareness." Conclusions: These findings suggest that MBIs reduce may disordered eating behaviors through empowering women to make positive choices about food, eating, and coping, without focusing on weight control. Future research is needed to examine whether these findings replicate in larger and more diverse samples, and how they can be used to optimize and implement eating-specific MBIs in community-based settings.

Is craving a risk factor for substance use among treatment-seeking individuals with alcohol and other drugs use disorders? A meta-analytic review

BACKGROUND

It is still unclear whether craving should be considered a key risk factor for substance-use behaviors (SUB) among treatment-seeking individuals with alcohol (AUD) and other drugs use disorders. Therefore, this study aims at clarifying this topic using a meta-analytic approach.

METHODS

Cohen's d was computed as effect size (ES) measure. Heterogeneity of ESs was computed using the Q statistic and I² index. The analyses also evaluated the impact assessment length on ESs. Furthermore, proximal effects of craving on SUB were compared to distal ones. The diagnoses of specific substance use disorders (SUDs), together with assessment instruments and research design were considered as additional moderators.

RESULTS

Thirty-six independent studies were included for a total of 4868 treatment-seeking individuals with SUDs. Patients who used substances showed slightly higher levels of craving than abstinent ones. The heterogeneity of results was large and significant. The length of period of assessment was positively related to ESs. The analyses highlighted no differences between pooled ESs of proximal and distal impacts of craving on SUB. The diagnoses of SUDs were significant moderators. Considering AUD, assessment instruments and research design were additional moderators.

CONCLUSIONS

Craving is a modest time-dependent proximal and distal risk factor for SUB among individuals with SUDs. Both the frequency of craving episodes and a heightened reactivity to craving cues are largely associated to SUB among individuals with AUD. Future studies should evaluate the mediating and moderating roles of self-regulatory mechanisms on the relationship between craving and SUB.

Mindful Awareness: Can a Neuro-Developmentally Timed Approach Prevent Youth Substance Misuse

Youth substance use remains a significant public health issue. Although there are numerous evidence-based substance use preventive interventions, room for program improvement remains. Mindfulness practice, due to its feasibility of implementation, capacity to promote neuro-networks associated with delayed substance use initiation and progression to substance use disorders, and efficacy in promoting protective and reducing risk factors associated with substance use, may constitute one strategy for increasing the effectiveness of substance use preventive interventions. However, mindfulness-based approaches to substance use prevention have yet to be systematically tested with youth. In this conceptual paper, we first define mindfulness and its potential, through practice, to strengthen neuro-circuitry associated with substance use disorders. We then review evidence supporting the effectiveness of mindfulness-based preventive interventions to promote protective factors and reduce risk factors known to predict youth substance use. Thus, a case is made for neuro-developmentally timed, mindfulness-based substance use preventive interventions, with the ultimate goal of preventing future substance misuse and associated health consequences.

Craving is impermanent and it matters: Investigating craving and cannabis use among young adults with problematic use interested in reducing use

Rates of problematic cannabis use have nearly doubled over the last decade, and peak onset for cannabis use disorders occurs during young adulthood. Craving for cannabis is hypothesized to be an important factor that maintains cannabis use among people who desire to stop or reduce their use, including many young adults. Previous studies that used single timepoint assessment methods to demonstrate a link between craving and cannabis use have found mixed predictive utility of measurements. The impermanent, or time-varying nature of craving may be responsible for mixed findings, leading to inaccuracies in retrospective recall and greater difficulty measuring craving and detecting its association with cannabis use. The current study compared intensive longitudinal assessments and single timepoint assessments predicting cannabis use among young adults with problematic cannabis use who reported a desire to reduce their use. Participants (N = 80) completed a baseline craving questionnaire and intensive longitudinal assessments of momentary craving and cannabis use up to four times per day for 14 days. Results suggested that averaged momentary craving predicted cannabis use above-and-beyond craving measured at baseline. An increase of one SD above the sample-mean for averaged momentary craving increased the probability of cannabis use by 367 %, while a one SD increase in baseline craving was only associated with a 49 % increase. Findings suggest that asking young adults who want to cut back on their cannabis use about their craving at a single timepoint may not be as clinically useful as tracking cravings repeatedly in near real-time and in ecologically valid contexts.

Mindfulness as a predictor of cognitive-behavioral therapy outcomes in inner-city adults with posttraumatic stress and substance dependence

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is highly prevalent and difficult-to-treat. Mindfulness, defined as nonjudgmental attention to and awareness of present-moment experiences, represents a targetable mechanism with potential to predict and improve treatment outcomes for PTSD/SUD populations. We hypothesized that greater self-reported mindfulness at baseline (pre-treatment) would predict (a) lower end-of-treatment PTSD severity and (b) greater longest sustained abstinence during a 12-week cognitive-behavioral treatment program. Participants included 53 inner-city adults meeting at least four current symptoms of DSM-5 PTSD and current (DSM-IV) substance dependence (51% women; 75.5% African American; Mage = 45.42, SD = 9.99). Hierarchical regression analysis results indicated that higher levels of baseline mindfulness predicted lower end-of-treatment PTSD severity but not longest sustained abstinence from the primary substance of choice. Post hoc exploration of end-of-treatment PTSD symptom clusters indicated that higher baseline mindfulness predicted lower intrusion, negative alterations in cognitions and mood, and arousal and reactivity symptoms but not avoidance symptoms. Clinical and research implications are discussed.