A systematic review of the relationships between craving and smoking cessation

Tobacco Images Choice and Its Association with Craving and Dependence in People who Smoke Cigarettes

INTRODUCTION

Increased salience of drug-related cues over non-drug reinforcers can drive drug use and contribute to tobacco use disorder (TUD). An important scientific and clinical goal is to effectively measure this elevated drug-seeking behavior in TUD. However, most TUD assessments rely on self-reported cravings and cigarette consumption, not providing an objective measure of the impact of drug-cues on biasing behavior towards drugs. The probabilistic image choice (PIC) task investigates the choice of viewing drug-related pictures as compared to other salient pictures (e.g., pleasant and unpleasant). This study aimed to develop and validate the PIC task for TUD and evaluate the associations between behavioral choice and tobacco craving, daily cigarette consumption, quit attempts and motivation to quit, and nicotine dependence (the Fagerström score).

METHODS

We recruited 468 smokers and 121 nonsmokers using the Prolific online platform. Participants performed the PIC task twice (at a one-month interval) and completed other measures relevant to TUD.

RESULTS

compared to nonsmokers, tobacco smokers selected to view significantly more tobacco images and less pleasant (non-drug reinforcer) images, a profile that remained stable at retest. Individual differences in choice of tobacco as compared to pleasant images on the PIC task were associated with craving but not with the other tobacco dependence measures, suggesting that the task may serve as a behavioral proxy measure of drug "wanting" rather than of cumulative nicotine exposure or physical dependence.

CONCLUSIONS

these results suggest that the PIC task can be a valuable tool for objectively assessing craving-associated tobacco seeking in TUD.

IMPLICATIONS SECTION

which should provide a brief description about what the study addsMost of the current measures of tobacco use disorder (TUD) rely on self-reports of consumption, dependence and craving and do not take into consideration the role of drug-related cues in driving tobacco seeking. This study shows that the probabilistic image choice (PIC) task provides an objective, reliable proxy measure of tobacco image seeking behavior in people who smoke cigarettes that is linked to craving (desire) for smoking but not to other measures of TUD. Therefore, the PIC task may be a useful complementary tool for the classification, diagnosis, and prognosis of TUD.

Relationships Between the Nicotine Metabolite Ratio and Laboratory Assessments of Smoking Reinforcement and Craving Among Adults in a Smoking Cessation Trial

INTRODUCTION

People who metabolize nicotine more quickly are generally less successful at quitting smoking. However, the mechanisms that link individual differences in the nicotine metabolite ratio (NMR), a phenotypic biomarker of the rate of nicotine clearance, to smoking outcomes are unclear. We tested the hypotheses that higher NMR is associated with greater smoking reinforcement, general craving, and cue-induced cigarette craving in a treatment-seeking sample.

METHODS

Participants were 252 adults who smoke cigarettes enrolled in a randomized controlled smoking cessation trial (NCT03262662) conducted in Buffalo, New York, USA. Participants completed the Choice Behavior Under Cued Conditions (CBUCC) paradigm, a laboratory choice procedure, ~1 week before the first cessation treatment visit, at which time a saliva sample was collected for NMR assessment. On each CBUCC trial, participants reported cigarette craving during cue presentation (cigarette, water) and spent $0.01-$0.25 for a chance (5%-95%) to sample the cue (one puff, sip), providing measures of smoking reinforcement (spending for cigarettes vs. water), general cigarette craving (averaged across cigarette and water cues), and cue-specific craving (cigarette craving during cigarette vs. water cues).

RESULTS

As observed in prior work, the NMR was significantly higher among White and female participants. As expected, both spending and cigarette craving were significantly greater on cigarette compared to water trials. However, contrary to our hypotheses, higher NMR was not associated with greater smoking reinforcement, general craving, or cue-specific craving.

CONCLUSIONS

The present data do not support that smoking reinforcement or craving is related to nicotine metabolism among individuals seeking to quit smoking.

IMPLICATIONS

Though greater smoking reinforcement, general craving, and cue-specific craving are hypothesized to be linked to faster nicotine metabolism, there was no evidence of such relationships in the present sample of adults seeking to quit smoking. Further research, including replication and consideration of alternate hypotheses, is warranted to elucidate the mechanisms by which the NMR is related to smoking cessation.

Cigarette craving in virtual reality cue exposure in abstainers and relapsed smokers

Cue exposure therapy (CET) in substance-use disorders aims to reduce craving and ultimately relapse rates. Applying CET in virtual reality (VR) was proposed to increase its efficacy, as VR enables the presentation of social and environmental cues along with substance-related stimuli. However, limited success has been reported so far when applying VR-CET for smoking cessation. Understanding if effects of VR-CET differ between future abstainers and relapsing smokers may help to improve VR-CET. Data from 102 participants allocated to the intervention arm (VR-CET) of a recent RCT comparing VR-CET to relaxation in the context of smoking cessation was analyzed with respect to tolerability, presence, and craving during VR-CET. Cue exposure was conducted in four VR contexts (Loneliness/Rumination, Party, Stress, Café), each presented twice. Relapsed smokers compared to abstainers experienced higher craving during VR-CET and stronger craving responses especially during the Stress scenario. Furthermore, lower mean craving during VR-CET positively predicted abstinence at 6-month follow-up. Attempts to improve smoking cessation outcomes of VR-CET should aim to identify smokers who are more at risk of relapse based on high craving levels during VR-CET. Specifically measuring craving responses during social stress seems to be well suited to mark relapse. We propose to investigate individualized treatment approaches accordingly.

Tobacco Images Choice and Its Association with Craving and Dependence in Cigarette Smokers

Introduction

Increased salience of drug-related cues over non-drug reinforcers can drive drug use and contribute to tobacco use disorder (TUD). An important scientific and clinical goal is to effectively measure this elevated drug-seeking behavior in TUD. However, most TUD assessments rely on self-reported cravings and cigarette consumption, not providing an objective measure of the impact of drug-cues on biasing behavior towards drugs. The probabilistic image choice (PIC) task investigates the choice of viewing drug-related pictures as compared to other salient pictures (e.g., pleasant and unpleasant). This study aimed to develop and validate the PIC task for TUD and evaluate the associations between behavioral choice and tobacco craving, daily cigarette consumption, quit attempts and motivation to quit, and nicotine dependence (the Fagerström score).

Methods

We recruited 468 smokers and 121 nonsmokers using the Prolific online platform. Participants performed the PIC task twice (at a one-month interval) and completed other measures relevant to TUD.

Results

compared to nonsmokers, tobacco smokers selected to view significantly more tobacco images and less pleasant (non-drug reinforcer) images, a profile that remained stable at retest. Individual differences in choice of tobacco as compared to pleasant images on the PIC task were associated with craving but not with the other tobacco dependence measures, suggesting that the task may serve as a behavioral proxy measure of drug "wanting" rather than of cumulative nicotine exposure or physical dependence.

Conclusions

these results suggest that the PIC task can be a valuable tool for objectively assessing craving-associated tobacco seeking in TUD.

Craving dynamics and related cerebral substrates predict timing of use in alcohol, tobacco, and cannabis use disorders

Background

Patients treated for Substance Use Disorders exhibit highly fluctuating patterns of craving that could reveal novel prognostic markers of use. Accordingly, we 1) measured fluctuations within intensively repeated measures of craving and 2) linked fluctuations of craving to connectivity indices within resting-state (rs) brain regions to assess their relation to use among patients undergoing treatment for Alcohol, Tobacco and Cannabis Use Disorders.

Method

Participants -64 individuals with SUD for tobacco, alcohol, or cannabis and 35 healthy controls-completed a week of Ecological Momentary Assessment (EMA) during which they reported craving intensity and substance use five times daily. Before EMA, a subsample of 50 patients, and 34 healthy controls also completed resting-state (rs)-MRI acquisitions. Craving temporal dynamics within each day were characterized using Standard Deviation (SD), Auto-Correlation Factor (ACF), and Mean Successive Square Difference (MSSD). Absolute Difference (AD) in craving between assessments was a prospective prediction measure.

Results

Within-day, higher MSSD predicted greater substance use while controlling for mean craving. Prospectively higher AD predicted later increased substance use independently of previous use or craving level. Moreover, MSSD was linked to strength in five functional neural connections, most involving frontotemporal systems. Cerebello-thalamic and thalamo-frontal connectivity were also linked to substance use and distinguished the SUD from the controls.

Conclusion

To the best of our knowledge, this is the first study to indicate that instability in craving may be a trigger for use in several SUD types, beyond the known effect of craving intensity.

Associations between nicotine product use and craving among stable daily and non-daily users

Nicotine craving typically develops shortly after last use and is conceptualized as essential to the development, maintenance, and treatment of nicotine dependence. Previous research has primarily examined the relationship between craving and use among individuals trying to quit smoking, and less is known about this relationship among active users, particularly e-cigarette users. The current study evaluated the association between craving and use by assessing both constructs twice daily over 7 days in a sample of daily (n = 80) and non-daily (n = 34) users of combustible tobacco and e-cigarette products. We used negative binomial regression modeling to analyze the relationship between nicotine craving and use in two ways. First, we evaluated a lagged model in which craving at the time of assessment predicted use during the next time period. Next, we evaluated a model in which maximum craving since the last assessment predicted use during the same time period. Maximum craving was significantly and positively associated with nicotine product use (p <.05) while craving at the time of assessment was not. These associations did not differ depending on use frequency or on specific products used. Findings provide evidence that self-report ratings of craving are associated with greater nicotine and tobacco product use for both frequent and intermittent users. Furthermore, these results may be useful in developing or modifying interventions for a wide variety of nicotine users, including those who are not yet intending to make a change to their nicotine use.

Modeling Idiographic Longitudinal Relationships between Affect and Cigarette Use: An Ecological Momentary Assessment Study

Background: Despite public knowledge of the adverse health effects of tobacco use, cigarettes remain widely used due to the addictive nature of nicotine. Physiologic adaptation to the presence of nicotine over time leads to unpleasant effects during withdrawal periods. Alongside these physiological effects, tobacco users often report changes in their consumption of tobacco in response to their emotional state. Objectives: We hypothesized that idiographic, or person-specific level, increases in participants' negative affect (NA) and positive affect (PA) ratings at a given time point would be associated with higher and lower craving and smoking over the following several hours, respectively. Fifty-two participants completed block randomized ecological momentary assessment surveys on their smartphones 4 times per day for 30 days, reporting from 0-100 their level of seven discrete emotions, stress, current craving, and smoking behavior. We analyzed the relationships between affect and smoking and craving using idiographic generalized linear models. Results: While some participants exhibited the hypothesized relationships, each participant varied in the strength and direction of the relationships between affect and craving/smoking. These outcomes were partially moderated at the group level by anxiety/depression at baseline, but not by level of nicotine dependence or sex. Conclusions: This suggests that the factors driving cigarette use vary significantly between individuals.

Cue-reactivity targeted smoking cessation intervention in individuals with tobacco use disorder: a scoping review

Objectives

Cue-reactivity is a critical step leading to the emergence of addictive psychology and the triggering of addictive behaviors within the framework of addiction theory and is considered a significant risk factor for addiction-related behaviors. However, the effect of cue-reactivity targeted smoking cessation intervention and the cue-reactivity paradigms used in the randomized controlled trials varies, which introduces more heterogeneity and makes a side-by-side comparison of cessation responses difficult. Therefore, the scoping review aims to integrate existing research and identify evidence gaps.

Methods

We searched databases in English (PubMed and Embase) and Chinese (CNKI and Wanfang) using terms synonymous with 'cue' and 'tobacco use disorder (TUD)' to April 2023, and via hand-searching and reference screening of included studies. Studies were included if they were randomized controlled trials taking cue-reactivity as an indicator for tobacco use disorder (TUD) defined by different kinds of criteria.

Results

Data were extracted on each study's country, population, methods, timeframes, outcomes, cue-reactivity paradigms, and so on. Of the 2,944 literature were retrieved, 201 studies met the criteria and were selected for full-text screening. Finally, 67 pieces of literature were selected for inclusion and data extraction. The results mainly revealed that non-invasive brain stimulation and exercise therapy showed a trend of greater possibility in reducing subjective craving compared to the remaining therapies, despite variations in the number of research studies conducted in each category. And cue-reactivity paradigms vary in materials and mainly fall into two main categories: behaviorally induced craving paradigm or visually induced craving paradigm.

Conclusion

The current studies are still inadequate in terms of comparability due to their heterogeneity, cue-reactivity can be conducted in the future by constructing a standard library of smoking cue materials. Causal analysis is suggested in order to adequately screen for causes of addiction persistence, and further explore the specific objective cue-reactivity-related indicators of TUD.

Bayesian continuous-time hidden Markov models with covariate selection for intensive longitudinal data with measurement error

Intensive longitudinal data collected with ecological momentary assessment methods capture information on participants' behaviors, feelings, and environment in near real-time. While these methods can reduce recall biases typically present in survey data, they may still suffer from other biases commonly found in self-reported data (e.g., measurement error and social desirability bias). To accommodate potential biases, we develop a Bayesian hidden Markov model to simultaneously identify risk factors for subjects transitioning between discrete latent states as well as risk factors potentially associated with them misreporting their true behaviors. We use simulated data to demonstrate how ignoring potential measurement error can negatively affect variable selection performance and estimation accuracy. We apply our proposed model to smartphone-based ecological momentary assessment data collected within a randomized controlled trial that evaluated the impact of incentivizing abstinence from cigarette smoking among socioeconomically disadvantaged adults. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Neuroaffective reactivity profiles are associated with vulnerability to e-cigarette use

BACKGROUND

We tested whether neuroaffective responses to motivationally salient stimuli are associated with vulnerability to cue-induced e-cigarette use in e-cigarette naïve adults who smoke daily. We hypothesized that individuals with stronger neuroaffective responses to nicotine-related cues than to pleasant stimuli (the C>P reactivity profile) would be more vulnerable to cue-induced nicotine self-administration than individuals with stronger neuroaffective responses to pleasant stimuli than to nicotine-related cues (the P>C reactivity profile).

METHODS

We used event-related potentials (ERPs, a direct measure of cortical activity) to measure neuroaffective reactivity to pleasant, unpleasant, neutral, and nicotine-related cues indicating the opportunity to use an e-cigarette in 36 participants. For each picture category, we computed the amplitude of the late positive potential (LPP), a robust index of motivational salience. To identify each individual's neuroaffective reactivity profile we applied k-means cluster analysis on the LPP responses. We compared the e-cigarette use frequency across profiles using quantile regression for counts.

RESULTS

K-means cluster analysis assigned 18 participants to the C>P profile and 18 participants to the P>C profile. Individuals with the C>P neuroaffective profile used the e-cigarette significantly more often than those with the P>C profile. Significant differences in the number of puffs persisted across different quantiles.

CONCLUSIONS

These results support the hypothesis that individual differences in the tendency to attribute motivational salience to drug-related cues underlie vulnerability to cue-induced drug self-administration. Targeting the neuroaffective profiles that we identified with tailored treatments could improve clinical outcomes.

Effects of short-term nicotine deprivation on delay discounting among young, experienced, exclusive ENDS users: An initial study

Delay discounting describes how rapidly delayed rewards lose value as a function of delay and serves as one measure of impulsive decision-making. Nicotine deprivation among combustible cigarette smokers can increase delay discounting. We aimed to explore changes in discounting following nicotine deprivation among electronic nicotine delivery systems (ENDS) users. Thirty young adults (aged 18-24 years) that exclusively used ENDS participated in two laboratory sessions: one with vaping as usual and another after 16 hr of nicotine deprivation (biochemically assessed). At each session, participants completed a craving measure and three hypothetical delay discounting tasks presenting choices between small, immediate rewards and large, delayed ones (money-money; e-liquid-e-liquid; e-liquid-money). Craving for ENDS significantly increased during short-term nicotine deprivation relative to normal vaping. Delay discounting rates in the e-liquid now versus money later task increased (indicating a shift in preference for smaller, immediate rewards) following short-term nicotine deprivation relative to vaping as usual, but no changes were observed in the other two discounting tasks. Short-term nicotine deprivation increased the preference for smaller amounts of e-liquid delivered immediately over larger, monetary awards available after a delay in this first study of its kind. As similar preference shifts for drug now versus money later have been shown to be indicative of increased desire to use drug as well as relapse risk, the findings support the utility of the current model as a platform to explore interventions that can mitigate these preference shifts. (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.

Addicted to green: priming effect of menthol cigarette packaging on brain response to smoking cues

INTRODUCTION

Mentholated tobacco cigarettes are believed to be more addictive than non-menthol ones. Packaging of most menthol cigarette brands includes distinctive green hues, which may act as conditioned stimuli (ie, cues) and promote menthol smoking. To examine the cue properties of menthol cigarette packaging, we used a priming paradigm to assess the effect of packaging on the neural substrates of smoking cue reactivity. We hypothesised that menthol packaging will exert a specific priming effect potentiating smoking cue reactivity in menthol compared with non-menthol smokers.

METHODS

Forty-two menthol and 33 non-menthol smokers underwent functional MRI while viewing smoking and neutral cues. The cues were preceded (ie, primed) by briefly presented images of menthol or non-menthol cigarette packages. Participants reported craving for cigarettes in response to each cue.

RESULTS

Menthol packaging induced greater frontostriatal and occipital smoking cue reactivity in menthol smokers than in non-menthol smokers. Menthol packaging also enhanced the mediation by neural activity of the relationship between cue exposure and cigarette craving in menthol but not non-menthol smokers. Dynamic causal modelling showed stronger frontostriatal-occipital connectivity in response to menthol packaging in menthol compared with non-menthol smokers. The effects of non-menthol packaging did not differ between categories of smokers.

CONCLUSIONS

Our findings demonstrate heightened motivational and perceptual salience of the green-hued menthol cigarette packaging that may exacerbate menthol smokers' susceptibility to smoking cues. These effects could contribute to the greater addiction severity among menthol smokers and could be considered in the development of science-based regulation and legal review of tobacco product marketing practices.

Effectiveness of personalized tobacco cessation intervention package among patients with schizophrenia and related psychotic disorders - A two-group experimental study

INTRODUCTION

Persons with schizophrenia and related psychotic disorders (PwS) smoke more, and have twice the rate of mortality, with 10-25 years lower life expectancy than the general population. Evidence-based tobacco cessation interventions would help in quitting.

AIM

To evaluate the effectiveness of a personalized tobacco cessation intervention package for patients attending the outpatient psychiatry department.

METHODS

The study adopted a two-group experimental design in PwS, using a simple randomization method. Eligible participants were randomly allocated to either the intervention group (n = 85) receiving the intervention package or the control group (n = 85) receiving brief advice to stop tobacco. The study outcomes were measured at baseline, 1, 3, and 6 months. SPSS 23 was used for data analysis. Intention-to-treat analysis was used to manage missing data. The p-value of < 0.05 is considered statistically significant.

RESULTS

At 6 months, there was a significant difference (p < 0.001) in 7 days point-prevalence abstinence (28 % vs 10.8 %), reduction of tobacco by at least 50 % (62.4 % vs 40.9 %) with an attrition rate of 15.3 % vs 30.5 % in intervention and control group respectively. Reduction in nicotine dependence and tobacco craving, an increase in motivation level, quit attempts and clinical improvement favored the intervention group. 16.5 % of participants expressed interest in pharmacotherapy for tobacco cessation, 3.5 % were referred to a specialized tobacco cessation center, two control group participants were hospitalized for drug default, and withdrawal symptoms reported were mild.

CONCLUSION

Implementing a tobacco cessation intervention based on the stage of motivation aids in abstinence and reduction of tobacco use in PwS.

Association of Drug Cues and Craving With Drug Use and Relapse: A Systematic Review and Meta-analysis

Importance

Craving, which is a strong desire for drugs, is a new DSM-5 diagnostic criterion for substance use disorders (SUDs), which are the most prevalent, costly, and deadly forms of psychopathology. Despite decades of research, the roles of drug cues and craving in drug use and relapse remain controversial.

Objective

To assess whether 4 types of drug cue and craving indicators, including cue exposure, physiological cue reactivity, cue-induced craving, and self-reported craving (without cue exposure), are prospectively associated with drug use and relapse.

Data Sources

Google Scholar was searched for published studies from inception through December 31, 2018. In addition, backward and forward searches were performed on included articles to identify additional articles.

Study Selection

Included studies reported a prospective statistic that linked cue and craving indicators at time 1 to drug use or relapse at time 2, in humans.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Study characteristics and statistics were extracted and/or coded by 1 of the 2 authors and then checked by the other. Statistical analyses were performed from May to July 2021.

Main Outcomes and Measures

Random-effects models were used to calculate prospective odds ratios (ORs) representing the association between cue and craving indicators and subsequent drug use/relapse.

Results

A total of 18 205 records were identified, and 237 studies were included. Across 656 statistics, representing 51 788 human participants (21 216 with confirmed SUDs), a significant prospective association of all cue and craving indicators with drug use/relapse was found (OR, 2.05; 95% CI, 1.94-2.15), such that a 1-unit increase in cue and craving indicators was associated with more than double the odds of future drug use or relapse. A Rosenthal fail-safe analysis revealed that 180 092 null studies would need to be published to nullify this finding. Trim-and-fill analysis brought the adjusted effect size to an OR of 1.31 (95% CI, 1.25-1.38). Moderator analyses showed that some of the strongest associations were found for cue-induced craving, real cues or images, drug use outcome, same-day time lag, studies using ecological momentary assessment, and male participants.

Conclusions and Relevance

Findings from this systematic review and meta-analysis suggest that drug cue and craving indicators play significant roles in drug use and relapse outcomes and are an important mechanism underlying SUDs. Clinically, these results support incorporating craving assessment across stages of treatment, as early as primary care.

Logical fallacies and misinterpretations that hinder progress in translational addiction neuroscience

Substance use disorders (SUDs) are heterogeneous and complex, making the development of translationally predictive rodent and nonhuman primate models to uncover their neurobehavioral underpinnings difficult. Neuroscience-focused outcomes have become highly prevalent, and with this, the notion that SUDs are disorders of the brain embraced as a dominant theoretical orientation to understand SUD etiology and treatment. These efforts, however, have led to few efficacious pharmacotherapies, and in some cases (as with cocaine or methamphetamine), no pharmacotherapies have translated from preclinical models for clinical use. In this theoretical commentary, we first describe the development of animal models of substance use behaviors from a historical perspective. We then define and discuss three logical fallacies including 1) circular explanation, 2) affirming the consequent, and 3) reification that can apply to developed models. We then provide three case examples in which conceptual or logical issues exist in common methods (i.e., behavioral economic demand, escalation, and reinstatement). Alternative strategies to refocus behavioral models are suggested for the field to better bridge the translational divide between animal models, the clinical condition of SUDs, and current and future regulatory pathways for intervention development.

Impaired control in addiction involves cognitive distortions and unreliable self-control, not compulsive desires and overwhelmed self-control

Impaired control in addiction involves a characteristic but obscure kind of partial control. Certain aspects of control over drug use are clearly reduced, reflected in difficulty cutting back and relapse. However, other aspects of control are clearly preserved, as reflected in substantial sensitivity to situational incentives-for example, the ability to defer use when needed. This juxtaposition is puzzling, and a clear mechanistically precise understanding of impaired control has yet to emerge. In this article, a Distortion model of impaired control is put forward. The key insight of the model is that the puzzling pattern of partial control seen in addiction can be understood in terms of unreliable control. The model posits large populations of distorted automatic thoughts (e.g., about drugs, one's self, one's circumstances, and one's abilities to cope), coupled with unreliable control over these distorted thoughts. These distorted thoughts, typically gradually and cumulatively, lead to illusion-like misvaluation of costs and benefits of drug use, in turn eventually leading to decisions to use. The model captures an elusive middle ground in addiction in which substantially preserved control over drug use for briefer intervals coexists with difficulty maintaining sobriety over the long-term. Moreover, the model explains a range of clinical findings in addiction that are not easily accommodated on leading alternative views.

Association Between Negative Affectivity and Craving in Substance-Related Disorders: A Systematic Review and Meta-analysis of Direct and Indirect Relationships

BACKGROUND

A sizeable literature highlighted that negative affectivity and craving are both known to be implicated in relapses.

OBJECTIVES

The present study synthetized the existing litterature to determine strength of the interaction between negative affectivity and craving for substance-related disorders including illicit drugs, alcohol and tobacco.

METHODS

We conducted a systematic review in accordance with PRISMA guidelines followed by a meta-analysis. Online computer databases PubMed, PsycINFO and Web of Science were searched systematically and thoroughly. Jamovi 1.8.1 Current version was used to conduct meta-analysis.

RESULTS

Thirty studies were included in the review, and 14 of these, including 2257 subjects, were used for meta-analysis. The raw correlation ranged from 0.17 to 0.58, which indicated weak to moderate association between negative affects and craving. In total, approximately 90% of the selection revealed a positive correlation between negative affects and craving. Alcohol and tobacco use disorders have received the most attention. Additionally, negative affectivity was often defined as a transient state rather than a stable personality trait.

CONCLUSIONS

In both of our meta-analyses and in the narratively reported studies, we found that negative affectivity is an important component related to craving, but individual differences in craving reactivity existed.

Treating cocaine and opioid use disorder with transcranial magnetic stimulation: A path forward

Developing new, effective treatments for substance use disorders (SUDs), especially cocaine and opioid use disorders (CUD and OUD), are of immense importance. These are chronic, relapsing brain diseases characterized by dysregulated circuits manifesting from neuroplastic change brought on by repeated exposure to substances of abuse. A potential treatment is therapeutically inducing neuroplastic change in targeted dysregulated circuits. One such intervention, repetitive transcranial magnetic stimulation (rTMS) has gained traction over the past two decades as a method of noninvasively stimulating cortical structures in order to induce subcortical neuroplastic change. By doing so, rTMS ameliorates symptoms that are consequent of dysregulations in disease-related circuits, such as craving, and reduces drug use. Although rTMS has been successfully applied as a treatment for other clinical disorders, progress toward treatment applications for SUDs has been stymied by what we dub "known unknowns". These are fundamental lines of research within the rTMS-SUD field that have yet to be systematically understood which could help to optimize TMS as an intervention for SUDs. Because progress in treatment for CUD and OUD is imperative given the widespread severity of OUD and the lack of treatment for CUD, it is necessary to critically reflect on the ways in which rTMS research for these disorders can most effectively move forward to help patients. We articulate six "known unknowns" and outline a direction of research to address each. Briefly, the "known unknowns" in the field are: 1) Cortical target selection, 2) subcortical circuit engagement, 3) optimizing rTMS sequences, 4) rTMS as an adjuvant to existing interventions, 5) manipulating brain state, and 6) selecting outcome measures. We also outline research design approaches to address these "known unknowns" in the rTMS-SUDs field. Unification of efforts across research laboratories is necessary to develop empirically validated treatments that will benefit patients in a timely fashion.

Combined smoking and alcohol cues: Effects on craving, drug-seeking, and consumption

BACKGROUND

Alcohol and cigarettes are commonly used together, but little is known about their joint motivational impact. Cue reactivity studies have customarily examined alcohol and smoking cues in isolation, despite the potential for cues to elicit stronger motivational responses when combined. This study used a validated cue reactivity procedure (Choice Behavior Under Cued Conditions) systematically to disentangle the separate and joint effects of alcohol and cigarette cues on substance use motivation.

METHODS

Participants were 110 adults (M_age  = 34.0, SD = 10.8) who consumed both cigarettes and alcohol. Participants completed 40 cue reactivity trials with four in vivo cue types: water, alcohol, cigarette, and combined cigarette and alcohol. Participants rated their craving prior to receiving opportunities to spend real money to gain access to the cues. Spending larger amounts of money increased the probability that the substance(s) would be available for consumption. When granted access, participants took one cigarette puff and/or sip of the beverage. A multimethod approach assessed three key motivational indices: craving, drug-seeking (spending, latency to access the cue), and consumption (puff duration, alcohol consumed). Effects of cue type and rates of substance use (cigarettes per day, drinks per day, relative frequency of co-use) were assessed using hierarchical linear models.

RESULTS

Both alcohol and smoking cues enhanced cue-specific craving but not craving for the alternative substance. In a novel finding, combined cues elicited higher craving and greater spending than single-drug cues. All drug cues elicited greater spending than water cues, and spending was moderated by the relative frequency of co-use.

CONCLUSIONS

We found that combined alcohol and cigarette cues provoke more powerful craving and drug-seeking responses and, therefore, may be more motivationally potent among individuals who use multiple substances.

Daily support seeking as coping strategy in dual-smoker couples attempting to quit

OBJECTIVE

Smoking cessation is a stressful event and lapses are frequent. The dynamic model of relapse has been criticized for not integrating interpersonal factors as phasic influences. Seeking social support, as a coping strategy to deal with cravings, may help to refrain from smoking.

DESIGN

Overall, 83 heterosexual dual-smoker couples reported on their craving, the extent of seeking social support from one's partner regarding smoking cessation, and their number of cigarettes smoked in smartphone-based end-of-day diaries, from a joint self-set quit date on across 22 consecutive days.

MAIN OUTCOME MEASURE

Number of cigarettes smoked.

RESULTS

Multilevel analyses indicated that on days with higher-than-average levels of craving, male and female smokers reported more cigarettes smoked. Higher-than-usual support seeking was related to fewer cigarettes smoked that same day. For women only, we found a within-person interaction between craving and support seeking on smoking. On days with higher-than-average support-seeking, the effect of craving on smoking was attenuated.

CONCLUSION

Findings confirm the relevance of interpersonal processes in the relapse process, such as support seeking as coping behavior. Further, as a 'first act' in initiating supportive interactions, support seeking is an important piece in the social support process and a promising target for interventions.

A mindfulness-based, stress and coping model of craving in methamphetamine users

There is increasing interest in the role of mindfulness and mindfulness-based interventions to optimize recovery from a substance use disorder (SUD). However, relatively little is known about the theory-based psychological and social pathways whereby mindfulness could have beneficial effects for managing a chronic, relapsing SUD. Informed by Revised Stress and Coping Theory, the present cross-sectional study examined affective, cognitive, and social pathways whereby mindfulness is associated with lower methamphetamine craving. A total of 161 HIV-positive, methamphetamine-using sexual minority men completed a screening visit for a randomized controlled trial. Using a hybrid structural equation model, we examined pathways whereby mindfulness is associated with lower methamphetamine craving. We found that greater mindfulness was directly associated with lower negative affect and higher positive affect as well as indirectly associated with less methamphetamine craving. Interestingly, the indirect association between mindfulness and methamphetamine craving appeared to be uniquely attributable to positive affect. Only positive affect was indirectly associated with lower methamphetamine craving via higher positive re-appraisal coping and greater self-efficacy for managing triggers for methamphetamine use. Methamphetamine craving was supported by moderate associations with greater substance use severity and more frequent methamphetamine use. These findings support the role of mindfulness in cultivating positive affect, which could be crucial to build the capacity of individuals to manage methamphetamine craving as a chronic stressor that threatens recovery from SUD.

Efectos de algunas señales visuales y olfativas sobre el consumo de cigarrillo y el ansia para fumar

Las señales inductoras para el consumo (SIC) son uno de los factores que inciden en que un fumador encienda, o no, el próximo cigarrillo. Las SIC impactan más a los fumadores no dependientes de la nicotina (FND) que a los fumadores dependientes (FD). Los FND no son dependientes de la nicotina y sus niveles de monóxido de carbono tienden a ser más bajos. Los FD muestran niveles de nicotina y monóxido de carbono más altos (dependientes). Este estudio evaluó el nivel de ansia de los individuos frente a imágenes relacionadas con el producto (cigarrillos y cajetilla de cigarrillos) y si existen diferencias entre inductores visuales y olfativos en relación con el consumo de cigarrillo. Los FD muestran niveles de nicotina y monóxido de carbono más altos. Los participantes mostraron mayor ansia ante las imágenes que presentaban cigarrillos saliendo de la cajetilla. No se hallaron diferencias entre inductores visuales y olfativos en relación con el consumo de cigarrillo. No obstante, la ocurrencia de fumar fue mayor en FD que en FND. Por eso, es importante clasificar el tipo de fumador en futuras investigaciones que pretendan evaluar esta población. 

A Meta-Analysis of Cue Reactivity in Tobacco Cigarette Smokers

INTRODUCTION

The cue reactivity paradigm allows for systematic evaluation of motivational responses to drug-related cues that may elicit drug use. The literature on this topic has grown substantially in recent decades, and the methodology used to study cue reactivity has varied widely across studies. The present research provided a meta-analytic investigation of variables that have an impact on cue reactivity effects to enhance our understanding of this key feature of tobacco use disorders.

METHODS

A total of 128 publications yielded 249 effect sizes, which were analyzed to investigate the magnitude of the cue reactivity effect and potential moderators.

RESULTS

Craving generated a moderate-to-large effect size (Hedges' g = 0.71, p < .001), indicating that drug cues produced significantly greater craving than neutral cues. However, physiological variables yielded significantly lower or nonsignificant effect sizes. Analyses of a variety of empirically and theoretically relevant moderator variables showed that cue modality, cue personalization, cue reactivity environment, and the use of multiple assessments of cue reactivity were significantly associated with the magnitude of cue-specific craving effects (ps < .001). Effect sizes were not significantly related to abstinence status, gender, cigarettes per day, and treatment-seeking status.

CONCLUSIONS

The results underscored the strength of self-reported craving as an index of cue reactivity across studies, which support theories that posit cue reactivity is core to the addictive process for daily tobacco cigarette smokers. The present research further elucidates the variables that alter the cue reactivity effects across studies and provides recommendations for future cue reactivity research.

IMPLICATIONS

A core feature of addiction is that drug-related cues can have a major impact on motivational responses across multiple substance use disorders, including tobacco cigarettes. This paper describes a meta-analysis updating and synthesizing cue reactivity research with tobacco cigarette smokers over the last 20 years, a time of rapid growth for this literature. The study leads to a better understanding of the cue reactivity paradigm across different self-report and physiological variables and identifies factors that may modulate addictive motivation for tobacco cigarettes.

Craving management: Exploring factors that influence momentary craving-related risk of cannabis use among young adults

Young adult frequent cannabis use has increased in prevalence and some frequent users have problems reducing their use. A strong link between momentary craving and subsequent use behaviors among individuals with problematic cannabis use has been reported in the literature, including young adults. In treatment contexts, interventions based on associative learning and reinforcement aim to reduce the prevalence of problematic substance use by altering the association between craving and use by increasing craving management skills such as mindfulness and reducing unhelpful responding such as avoidance or suppression. However, this model has not been tested among young adult cannabis users. The current study examined the influence of trait and state craving management strategies (mindfulness, coping style, experiential avoidance, and craving beliefs) on the link between momentary craving and use, using ecological momentary assessment in a sample of young adults with problematic use interested in reducing their use. Results demonstrated that two craving management constructs were associated with use: non-reactivity (p = 0.02) and non-judgment (p < 0.01). Interactions with momentary craving were observed for two constructs: non-judgmentalness (p = 0.02) and craving beliefs (p < 0.01). Findings suggest that treatments that increase non-reactivity and non-judgmentalness may reduce the occurrence of cannabis use for young adults contemplating reduction during an important period of biopsychosocial development by mitigating the impact of craving or directly reducing use. Additionally, negative beliefs about craving may serve a protective function during acute periods of elevation in momentary craving, an unexpected finding deserving further investigation.

A Brief Motivational Intervention Differentially Reduces Sugar-sweetened Beverage (SSB) Consumption

Background

Environmental and behavioral interventions hold promise to reduce sugar-sweetened beverage (SSBs) consumption.

Purpose

To test, among frequent SSB consumers, whether motivations to consume SSBs moderated the effects of (a) a workplace SSB sales ban (environmental intervention) alone, and (b) a “brief motivational intervention” (BI) in addition to the sales ban, on changes in SSB consumption.

Methods

We assessed whether (1) baseline motivations to consume SSBs (craving, psychological stress, or taste enjoyment) impacted changes in daily SSB consumption at 6-month follow-up among frequent (>12oz of SSBs/day) SSB consumers (N = 214); (2) participants randomized to the BI (n = 109) versus to the sales ban only (n = 105) reported greater reductions in SSB consumption at follow-up; and (3) motivations to consume SSBs moderated any changes in SSB consumption.

Results

In response to the sales ban alone, individuals with stronger SSB cravings (+1 SD) at baseline showed significantly smaller reductions in daily SSB consumption at 6-month follow-up relative to individuals with weaker (−1 SD) SSB cravings (2.5 oz vs. 22.5 oz), p < .01. Receiving the BI significantly increased reductions for those with stronger SSB cravings: Among individuals with stronger cravings, those who received the BI evidenced significantly greater reductions in daily SSB consumption [M(SE) = −19.2 (2.74) oz] than those who did not [M(SE) = −2.5 (2.3) oz, p < .001], a difference of 16.72 oz.

Conclusions

Frequent SSB consumers with stronger SSB cravings report minimal reductions in daily SSB consumption with a sales ban only, but report greater reductions if they also receive a motivational intervention. Future multilevel interventions for institutions should consider both environmental and individualized multi-level interventions.

Clinical Trial information

NCT02585336.

Brief mindfulness training for smoking cessation in Chinese women in workplaces: A pilot randomized controlled trial

INTRODUCTION

Mindfulness training (MT) has shown preliminary efficacy as a behavioral treatment for smoking cessation. We examined the effect of a brief-MT intervention on smoking cessation for Chinese women in workplaces in Hong Kong, China.

METHODS

In this pilot randomized controlled trial, 213 daily smokers were recruited from workplaces and computer-randomized into the intervention (n = 114) or control (n = 99) groups. Participants in both groups received a self-help booklet. Participants in the intervention group additionally attended 2 sessions of a brief-MT workshop. The primary outcome was self-reported 7-day point-prevalence abstinence (PPA) at 6 months. Secondary outcomes were biochemically validated abstinence (exhaled CO < 4 ppm and salivary cotinine < 10 ng/mL) and smoking reduction at 6 months. Analyses were done by intention to treat. We conducted a post-trial qualitative evaluation on participants in the intervention group (n = 14). Data were analyzed thematically.

RESULTS

At 6-month follow-up, self-reported 7-day PPA were similar between the intervention and control groups (18.4% vs. 21.2%; P = 0.61). Very few participated in biochemical validation (n = 17), and validated abstinence and smoking reduction rates showed no significant difference (5.3% vs. 11.1%, P = 0.12 and 20.2% vs. 20.2%, P = 1.00, respectively). A posteriori analysis showed that brief-MT participants who were psychologically engaged with the intervention had greater 6-month PPA. Qualitative evaluation showed brief-MT reduced stress but its effectiveness was restrained by the insufficient home practice.

CONCLUSIONS

This pilot trial on a brief-MT intervention for smoking cessation on Chinese women in workplaces showed feasibility, but improving compliance is needed to maximize the efficacy in future fully powered trials.

Relationship between the strength of craving as assessed by the Tobacco Craving Index and success of quitting smoking in Japanese smoking cessation therapy

BACKGROUND

We previously developed the Tobacco Craving Index (TCI) to assess craving of smokers. In the present study, we validated the relationship between the TCI grade over the 5 sessions of Japanese smoking cessation therapy (SCT) and success of quitting smoking among 889 Japanese patients.

METHODS

The Japanese SCT consists of 5 sessions of SCT (first session and sessions 2, 4, 8 and 12 weeks later). In the TCI questionnaire, patients are asked to rate their strength of craving and frequency of craving, each on a four-point Likert scale. Patients are classified into one of four grades based on their responses (0, I, II, III, with III indicating severe craving). The TCI questionnaire was administered to each participant at each session of the SCT. This study included participants of Japanese SCT who answered the TCI at the first session of the SCT at five Japanese smoking cessation clinics. Patients who dropped out of the SCT from the second to the fifth sessions were considered to have failed smoking cessation. To elucidate how much the TCI grade predicts smoking status at the last session, we performed multivariate logistic regression analysis with adjustment for confounding factors.

RESULTS

Participants who had higher TCI grade(III) in the 2nd through 5th sessions showed significantly lower probability for success of quitting smoking than those who had lower TCI grades(0 or I) (adjusted odds ratio: 2nd session: 0.30, 3rd session: 0.15, 4th session: 0.06, 5th session: 0.02).

CONCLUSIONS

We validated the usefulness of the TCI grade for assessing probability of quitting smoking by using a large number of smoking cessation settings.

Associations between affect, craving, and smoking in Korean smokers: An ecological momentary assessment study

Cigarette smoking remains the largest cause of preventable death in the United States and worldwide. In South Korea and other Asian countries, a large proportion of males smoke, increasing the need to examine cigarette smoking in these populations. Research suggests that the association between positive affect and negative affect, and between affect and craving, may differ across cultures, and that it is useful to examine these associations using Ecological Momentary Assessment (EMA). South Korean smokers (N = 20, Mean Age = 21.15, 25% female) completed baseline questionnaires and downloaded an EMA app which prompted 4 random assessments (RAs) each day for 1-week. At each assessment, participants responded to items assessing momentary negative affect (NA) and positive affect (PA), craving, and number of cigarettes smoked since the previous EMA assessment. Linear mixed models (LMMs) were used to analyze EMA data (544 assessments), separating out between- and within- subject associations. There was a significant positive association between positive affect and negative affect at the between-subjects level. Both positive affect and negative affect were significantly positively associated with craving at between-subjects and within-subject levels. Craving was associated with subsequent smoking behavior at the within-subjects level. Overall, results suggest that associations between positive affect and negative affect may be different in South Korean smokers than in Western smokers, and that there are robust associations between both negative and positive affect and craving.

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.

Two weeks of image-guided left dorsolateral prefrontal cortex repetitive transcranial magnetic stimulation improves smoking cessation: A double-blind, sham-controlled, randomized clinical trial

BACKGROUND

Previous studies have found that repetitive transcranial magnetic stimulation (rTMS) to the left dorsal lateral prefrontal cortex (LDLPFC) transiently reduces smoking craving, decreases cigarette consumption, and increases abstinence rates.

OBJECTIVE

We investigated whether 10 daily MRI-guided rTMS sessions over two weeks to the LDLPFC paired with craving cues could reduce cigarette consumption and induce smoking cessation.

METHODS

We enrolled 42 treatment-seeking nicotine-dependent smokers (≥10 cigarettes per day) in a randomized, double-blind, sham-controlled trial. Participants received 10 daily sessions over 2 weeks of either active or sham MRI-guided rTMS (10Hz, 3000 pulses each session) to the LDLPFC concurrently with video smoking cues. The primary outcome was a reduction in biochemically confirmed cigarette consumption with a secondary outcome of abstinence on the target quit date. We also recorded cue-induced craving and withdrawal symptoms.

RESULTS

Compared to sham (n = 17), participants receiving active rTMS (n = 21) smoked significantly fewer cigarettes per day during the 2-week treatment (mean [SD], 13.73[9.18] vs. 11.06[9.29], P < .005) and at 1-month follow-up (12.78[9.53] vs. 7.93[7.24], P < .001). Active rTMS participants were also more likely to quit by their target quit rate (23.81%vs. 0%, OR 11.67, 90% CL, 0.96-141.32, x2 = 4.66, P = .031). Furthermore, rTMS significantly reduced mean craving throughout the treatments and at follow-up (29.93[13.12] vs. 25.01[14.45], P < .001). Interestingly across the active treatment sample, more lateral coil location was associated with more success in quitting (-43.43[0.40] vs. -41.79[2.24], P < .013).

CONCLUSIONS

Daily MRI-guided rTMS to the LDLPFC for 10 days reduces cigarette consumption and cued craving for up to one month and also increases the likelihood of smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02401672.

Specific Relapse Predictors: Could Cognitive-Behavioral Treatment for Smoking Cessation Be Improved?

Relapse remains a frequent and complex phenomenon that is not yet well understood. An under-researched area of study that may provide relevant information concerns the assessment of specific post-treatment variables, rather than the composite measures commonly used to predict smoking relapse. The current study sought to examine the effects of post-treatment smoking-related variables, including withdrawal symptomatology, abstinence self-efficacy, and smoking urgency in negative-affect situations and smoking relapse at the 3 month follow-up. The sample comprised 130 participants who achieved abstinence for at least 24 h through a cognitive-behavioral smoking cessation treatment. Regression analysis was conducted for both composite measures and specific subscales and items. Data showed that composite measures of tobacco withdrawal, self-efficacy, and smoking urgency in negative-affect situations were not significant predictors of smoking relapse. However, the analysis including subscales, and specific items showed that lower self-efficacy in negative-affect-related situations (OR = 1.36) and three withdrawal symptoms—irritability/frustration/anger (OR = 2.99), restlessness/impatience (OR = 1.87), and craving (OR = 2.31)—were significant predictors of relapse. These findings offer new insights into the role of different smoking-related post-treatment variables in short-term relapse. Considering and specifically targeting these variables after achieving abstinence may potentially contribute to reducing smoking relapse.

Tobacco craving and withdrawal symptoms in psychiatric patients during a motivational enhancement intervention based on a 26-hour smoking abstinence period

INTRODUCTION

In psychiatric patients, tobacco withdrawal symptoms are frequently seen as a barrier to smoking cessation; however, further studies are warranted in this specific population.

METHODS

Patients receiving in- or out-patient mental health care participated in a motivational enhancement program including a 26-hour tobacco abstinence experience with professional support and optional nicotine replacement therapy. The study included 174 subjects, of whom 159 were evaluated 1 week before and at the end of the 26-hour abstinence period. Repeated assessments included the Minnesota Nicotine Tobacco Withdrawal Scale Revised (MNWS-R), two items of the Mood and Physical Symptoms Scale (MPSS) regarding craving, the State-Trait Anxiety Inventory (STAI-S), the Beck Depression Inventory (BDI-21), and the World Health Organization Well-Being Index (WHO-5).

RESULTS

More than half the participants (52.3%) succeeded in 26-hour smoking abstinence. Craving was the most frequent MNWS-R withdrawal symptom (28.3% scored ≥3 on a 0–4 scale). Comparison of pre- and post-intervention data revealed significant improvements in 13 of 16 MNWS-R symptoms as well as craving (MPSS) and well-being, and significant decreases in anxiety and depression. Increasing MNWS-R craving scores and greater depression were both significantly associated with lower success in the 26-hour smoking abstinence period.

CONCLUSIONS

The negative effects of tobacco withdrawal symptoms in psychiatric patients may be substantially overestimated. Participation in a supportive structured motivational intervention with a 26-hour smoking cessation experience was well tolerated and contributed to temporary improvements in mental state. Craving is an interesting symptom to evaluate during smoking cessation attempts.

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.

"Chasing the first high": memory sampling in drug choice

Although vivid memories of drug experiences are prevalent within clinical contexts and addiction folklore ("chasing the first high"), little is known about the relevance of cognitive processes governing memory retrieval to substance use disorder. Drawing on recent work that identifies episodic memory's influence on decisions for reward, we propose a framework in which drug choices are biased by selective sampling of individual memories during two phases of addiction: (i) downward spiral into persistent use and (ii) relapse. Consideration of how memory retrieval influences the addiction process suggests novel treatment strategies. Rather than try to break learned associations between drug cues and drug rewards, treatment should aim to strengthen existing and/or create new associations between drug cues and drug-inconsistent rewards.

Biomarkers and neuromodulation techniques in substance use disorders

Addictive disorders are a severe health concern. Conventional therapies have just moderate success and the probability of relapse after treatment remains high. Brain stimulation techniques, such as transcranial Direct Current Stimulation (tDCS) and Deep Brain Stimulation (DBS), have been shown to be effective in reducing subjectively rated substance craving. However, there are few objective and measurable parameters that reflect neural mechanisms of addictive disorders and relapse. Key electrophysiological features that characterize substance related changes in neural processing are Event-Related Potentials (ERP). These high temporal resolution measurements of brain activity are able to identify neurocognitive correlates of addictive behaviours. Moreover, ERP have shown utility as biomarkers to predict treatment outcome and relapse probability. A future direction for the treatment of addiction might include neural interfaces able to detect addiction-related neurophysiological parameters and deploy neuromodulation adapted to the identified pathological features in a closed-loop fashion. Such systems may go beyond electrical recording and stimulation to employ sensing and neuromodulation in the pharmacological domain as well as advanced signal analysis and machine learning algorithms. In this review, we describe the state-of-the-art in the treatment of addictive disorders with electrical brain stimulation and its effect on addiction-related neurophysiological markers. We discuss advanced signal processing approaches and multi-modal neural interfaces as building blocks in future bioelectronics systems for treatment of addictive disorders.

Assessment of the Choice Behavior Under Cued Conditions (CBUCC) paradigm as a measure of motivation to smoke under laboratory conditions

BACKGROUND AND AIMS

The Choice Behavior under Cued Conditions (CBUCC) task uses three indices of tobacco use (consumption, money spent to access a cigarette and latency to reach for a cigarette) to assess motivation to smoke under laboratory conditions. Initial research with this procedure has shown that it can evince cue-specific craving and differential responding for smoking versus a neutral cue. This study aimed to replicate these findings and assess the interaction of cue-specific craving and behavior with abstinence prior to testing.

DESIGN

A mixed repeated-measures between-groups factorial design was used. Participants attended a morning laboratory session in which they were randomized to remain abstinent or smoke as usual (between-groups factor) and returned in the afternoon to complete CBUCC. In this, participants were exposed to 40 experimental trials. In each trial they were exposed to a cigarette or water cue behind a movable glass door (repeated-measures factor).

SETTING

University at Buffalo, New York, USA.

PARTICIPANTS

Participants were 106 daily non-treatment-seeking cigarette smokers, data from 102 were used.

MEASUREMENTS

On each of 40 trials, participants rated cigarette craving, and behavioral measures from the CBUCC (money spent, latency to access the cue, puff duration) were recorded.

FINDINGS

Craving and CBUCC behavioral measures showed high internal reliability across trials (Cronbach alphas ranged from 0.88 to 0.98). Craving and money spent were higher in trials with the cigarette cue than the water cue (F₍₁₁₀₀₎  = 45.49, P < 0.001 and F₍₁₁₀₀₎  = 116.26, P < 0.001). Other CBUCC measures did not show a significant effect of cue type. The difference in spending between cigarette and water cues was larger for abstinent participants than non-abstinent participants (F₍₁₁₀₀₎  = 5.0, P = 0.03). Other CBUCC measures did not show a significant interaction between abstinence and cue type. Craving on smoking trials was significantly correlated with cigarette spending (r = 0.54, P < 0.001) in the non-abstinence condition but not in the abstinence condition.

CONCLUSIONS

Craving and 'money spent' in the Choice Behavior under Cued Conditions task (CBUCC) appears to be responsive to cigarette versus water cues, and money spent appears to show greater difference in responsiveness to cigarette than water cues after abstinence.

Depression as a moderator of the prospective relationship between mood and smoking

OBJECTIVE

Affective features of depression are uniquely involved in the depression-smoking relationship, and it follows that smokers with depression are likely to use cigarettes to alleviate negative affect. However, most ecological momentary assessment (EMA) studies demonstrate no relationship between mood and smoking, in general. Conversely, a small number of experimental studies suggest there is an association between mood and smoking and that the relationship is dependent on levels of depression. Researchers have yet to examine the impact of depression on the relationship between mood and smoking using EMA methodology. Accordingly, the aim of this study was to explore the relationship between depression, mood, and ad lib smoking among adults in "real time."

METHOD

Participants included 96 adult daily smokers (53% female, 67% non-Hispanic Black; age, M = 40.76, SD = 12.42) who completed baseline ratings of depressive symptoms and 7 consecutive days of in vivo data collection focused on cigarette smoking and associated mood and craving ratings.

RESULTS

Results indicated that depression moderates the prospective relationship between mood and smoking (even when controlling for craving), such that participants with higher levels of depressive symptoms smoke more cigarettes in response to an improvement in mood (relative to their average mood), whereas participants with lower levels of depressive symptoms smoke more in response to worsening mood states (relative to their average mood).

CONCLUSIONS

Attempting to maintain better mood may be a motivating factor for smoking among depressed individuals. These findings may be helpful in tailoring smoking cessation treatment programs for people exhibiting depressive symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Time-Varying Relations Between Risk Factors and Smoking Before and After a Quit Attempt

Introduction

Intensive longitudinal data (ILD) collected with ecological momentary assessments (EMAs) can provide a rich resource for understanding the relations between risk factors and smoking in the time surrounding a cessation attempt.

Methods

Participants (N = 142) were smokers seeking treatment at a safety-net hospital smoking cessation clinic who were randomly assigned to receive standard clinic care (ie, counseling and cessation medications) or standard care plus small financial incentives for biochemically confirmed smoking abstinence. Participants completed EMAs via study provided smartphones several times per day for 14 days (1 week prequit through 1 week postquit). EMAs assessed current contextual factors including environmental (eg, easy access to cigarettes, being around others smoking), cognitive (eg, urge to smoke, stress, coping expectancies, cessation motivation, cessation self-efficacy, restlessness), behavioral (ie, recent smoking and alcohol consumption), and affective variables. Temporal relations between risk factors and smoking were assessed using a logistic time-varying effect model.

Results

Participants were primarily female (57.8%) and Black (71.8%), with an annual household income of <$20000 per year (71.8%), who smoked 17.6 cigarettes per day (SD = 8.8). Individuals assigned to the financial incentives group had decreased odds of smoking compared with those assigned to usual care beginning 3 days before the quit attempt and continuing throughout the first week postquit. Environmental, cognitive, affective, and behavioral variables had complex time-varying impacts on smoking before and after the scheduled quit attempt.

Conclusions

Knowledge of time-varying effects may facilitate the development of interventions that target specific psychosocial and behavioral variables at critical moments in the weeks surrounding a quit attempt.

Implications

Previous research has examined time-varying relations between smoking and negative affect, urge to smoke, smoking dependence, and certain smoking cessation therapies. We extend this work using ILD of unexplored variables in a socioeconomically disadvantaged sample of smokers seeking cessation treatment. These findings could be used to inform ecological momentary interventions that deliver treatment resources (eg, video- or text-based content) to individuals based upon critical variables surrounding their attempt.

Effects of transcranial direct current stimulation on symptoms of nicotine dependence: A systematic review and meta-analysis

The purpose of this systematic review and meta-analysis was to investigate the effects of transcranial direct current stimulation (tDCS) on symptoms of nicotine dependence in treatment-seeking smokers. Twelve studies qualified for this meta-analysis, and we used 15 total comparisons from the included studies for the data synthesis. Primary outcome measures were changes in (a) cue-provoked craving and (b) smoking intake (i.e., the number of cigarettes smoked) between active tDCS stimulation and sham control groups. Random-effects model meta-analyses revealed significant positive effects of tDCS on seven cue-provoked craving comparisons (effect size = 0.422; P = .004) and eight smoking intake comparisons (effect size = 0.557; P = .004). Moderator variable analyses indicated that applying anodal-tDCS on the right dorsolateral prefrontal cortex (DLPFC) revealed significant positive effects on the cue-provoked craving with minimal heterogeneity. Further, applying cathodal-tDCS on DLPFC regions showed more positive effects on both cue-provoked craving and smoking intake than cathodal-tDCS on other brain regions. These findings suggested that tDCS modulating DLPFC activity can be an effective option for decreasing individual's smoking dependence symptoms.

Comparisons of early and delayed abstainers and its effects on long-term smoking cessation in Taiwan

Background

Different quitting trajectories may reflect the stages of behavior change among smokers. The nature of quitting patterns could help the public health sector to design appropriate cessation plans. This study compared demographic, health, and behavioral characteristics and the effects of long-term abstinence between early and delayed abstainers.

Methods

We retrospectively sampled 142 abstainers from smoking cessation clinic participants for a study conducted from January 1 to December 31, 2017. Baseline information was obtained at the first clinic visit, and phone interviews were conducted 2 weeks, 3 months, and 6 months later. The 7-day point prevalence abstinence was employed for measuring their quitting status. We defined early abstainers as those who attained abstinence by second week and delayed abstainers as those who had done so by the third month. We compared their characteristics and 6-month quit rates and examined potential predictors between the two quitting patterns.

Results

One hundred forty-two participants were included with 87 (61.3%) early abstainers and 55 (38.7%) delayed abstainers. Early abstainers were older with more comorbidities, presenting longer smoking duration, higher exhaled carbon monoxide (CO) concentration and Fagerstrom Test of Cigarette Dependence (FTCD) scores. The 6-month abstinence rate was high for both quitting patterns with no significant difference (83.9% versus 81.8%, p = 0.7462). Higher FTCD scores and exhaled CO concentration were potential predictors for early abstainers with adjusted odds ratio 1.16 (95% confidence interval [CI], 1.01–1.33) and 1.04 (95% CI, 1.00–1.08) respectively.

Conclusions

Our results associated early abstainers with older age, more comorbidities and higher nicotine dependence. Both groups achieved good long-term abstinence maintenance. Although early abstainers may achieve earlier reduction of health risks, smokers could still benefit from long-term abstinence if they can manage to quit smoking even at later phases of cessation courses.

Preliminary examination of the orexin system on relapse-related factors in cocaine use disorder

RATIONALE

Current evidence and literature reviews provide a strong justification for examining the orexin receptor (OXR) system as a therapeutic target in substance use disorders, including cocaine and other psychostimulants.

OBJECTIVES

In this preliminary, proof-of-concept examination of orexin modulation in humans with cocaine use disorder, we measured changes in domains tied to relapse: stress, sleep, cue reactivity, and inhibitory control. Additionally, mood symptoms (anxiety, depression), medication compliance, and side effects were assessed.

METHODS

Twenty non-treatment seeking subjects with cocaine use disorder (CUD) received either the OX₁R / OX₂R antagonist suvorexant PO or placebo at 10 PM daily for two weeks (10 mg week 1, 20 mg week 2). Using psychometrics, smart-watch actigraphy, a cold-pressor stress challenge, and eye-tracking technology, the following domains were examined: sleep, stress/anxiety, cue-reactivity (attentional bias, craving), and inhibitory control. Psychometric data were collected every M/W/F (7 time points). Laboratory data were collected weekly (3 time points).

RESULTS

Bayesian and frequentist generalized linear models were employed in parallel to examine the effects of suvorexant compared to placebo, with a Bayesian posterior probability threshold >80% as evidence of a signal for suvorexant. Notable results favoring suvorexant over placebo included fewer total anti-saccade errors, improved sleep actigraphy (sleep/awake periods), pre/post cold-pressor change in heart rate and salivary cortisol (all posterior probabilities >94%), and craving (posterior probability >87%).

CONCLUSIONS

Initial but restricted evidence is provided supporting the orexin system as a modulator of relapse-related processes in cocaine use disorder. Baseline differences in the main outcome variables were not experimentally controlled and differences in craving were observed at baseline. This, in combination with a limited sample size, constrain the nature of the project. The results may serve to inform more comprehensive future research.

Use of electronic nicotine delivery systems by pregnant women II: Hair biomarkers for exposures to nicotine and tobacco-specific nitrosamines

INTRODUCTION

Public awareness of electronic nicotine delivery systems (ENDS) has increased over time, and the perception that ENDS offer a safer alternative to cigarettes may lead some pregnant women to use them to reduce cigarette smoking during pregnancy. No previous studies have used metabolite levels in hair to measure nicotine exposure for ENDS users during pregnancy. We aimed to measure and compare levels of nicotine, cotinine, and tobacco-specific nitrosamines (TSNAs) in hair samples from pregnant women who were current ENDS users, current smokers, and current non-smokers. We also aimed to estimate the association between ENDS use/smoking and smallness for gestational age (SGA).

METHODS

We used hair specimens from pregnant women who were dual users (ENDS and cigarettes), smokers, and non-smokers from a prospective cohort study to estimate exposure to nicotine, cotinine, and TSNAs. The exposure biomarkers and self-reports of smoking and ENDS use were used in log-binomial regression models to estimate risk ratios (RRs) for SGA among offspring.

RESULTS

Nicotine concentrations for pregnant dual users were not significantly different from those for smokers (11.0 and 10.6 ng/mg hair, respectively; p=0.58). Similarly, levels of cotinine, and TSNAs for pregnant dual users were not lower than those for smokers. The RR for SGA was similar for dual users and smokers relative to nonsmokers, (RR=3.5, 95% CI: 0.8-14.8) and (RR=3.3, 95% CI: 0.9-11.6), respectively. Using self-reports confirmed by hair nicotine, the RR values for dual ENDS users and smokers were 8.3 (95% CI: 1.0-69.1) and 7.3 (95% CI:1.0-59.0), respectively.

CONCLUSIONS

We did not observe lower levels of nicotine, cotinine, and TSNAs for current dual users compared to smokers during pregnancy. The risk of SGA for offspring of pregnant dual users was similar to that for offspring of pregnant smokers. Future studies are needed to further estimate the magnitude of the association between ENDS use and smallness for gestational age.

Not all smokers appear to seek nicotine for the same reasons: implications for preclinical research in nicotine dependence

Tobacco use leads to 6 million deaths every year due to severe long-lasting diseases. The main component of tobacco, nicotine, is recognized as one of the most addictive drugs, making smoking cessation difficult, even when 70 percent of smokers wish to do so. Clinical and preclinical studies have demonstrated consistently that nicotine seeking is a complex behavior involving various psychopharmacological mechanisms. Evidence supports that the population of smokers is heterogeneous, particularly as regards the breadth of motives that determine the urge to smoke. Here, we review converging psychological, genetic and neurobiological data from clinical and preclinical studies supporting that the mechanisms controlling nicotine seeking may vary from individual to individual. It appears timely that basic neuroscience integrates this heterogeneity to refine our understanding of the neurobiology of nicotine seeking, as tremendous progress has been made in modeling the various psychopharmacological mechanisms driving nicotine seeking in rodents. For a better understanding of the mechanisms that drive nicotine seeking, we emphasize the need for individual-based research strategies in which nicotine seeking, and eventually treatment efficacy, are determined while taking into account individual variations in the mechanisms of nicotine seeking.

Real-Time fMRI Neurofeedback in Patients With Tobacco Use Disorder During Smoking Cessation: Functional Differences and Implications of the First Training Session in Regard to Future Abstinence or Relapse

One of the most prominent symptoms in addiction disorders is the strong desire to consume a particular substance or to show a certain behavior (craving). The strong association between craving and the probability of relapse emphasizes the importance of craving in the therapeutic process. Former studies have demonstrated that neuromodulation using real-time fMRI (rtfMRI) neurofeedback (NF) can be used as a treatment modality in patients with tobacco use disorder. The aim of the present project was to determine whether it is possible to predict the outcome of NF training plus group psychotherapy at the beginning of the treatment. For that purpose, neuronal responses during the first rtfMRI NF session of patients who remained abstinent for at least 3 months were compared to those of patients with relapse. All patients were included in a certified smoke-free course and took part in three NF sessions. During the rtfMRI NF sessions tobacco-associated and neutral pictures were presented. Subjects were instructed to reduce their neuronal responses during the presentation of smoking cues in an individualized region of interest for craving [anterior cingulate cortex (ACC), insula or dorsolateral prefrontal cortex]. Patients were stratified to different groups [abstinence (N = 10) vs. relapse (N = 12)] according to their individual smoking status 3 months after the rtfMRI NF training. A direct comparison of BOLD responses during the first NF-session of patients who had remained abstinent over 3 months after the NF training and patients who had relapsed after 3 months showed that patients of the relapse group demonstrated enhanced BOLD responses, especially in the ACC, the supplementary motor area as well as dorsolateral prefrontal areas, compared to abstinent patients. These results suggest that there is a probability of estimating a successful withdrawal in patients with tobacco use disorder by analyzing the first rtfMRI NF session: a pronounced reduction of frontal responses during NF training in patients might be the functional correlate of better therapeutic success. The results of the first NF sessions could be useful as predictor whether a patient will be able to achieve success after the behavioral group therapy and NF training in quitting smoking or not.

Mechanisms linking mindfulness and early smoking abstinence: An ecological momentary assessment study

Research has suggested that individuals with greater dispositional mindfulness (i.e., nonjudgmental, present-focused attention) are more likely to quit smoking, but the underlying mechanisms are unclear. This study investigated mechanisms linking mindfulness and early smoking abstinence using ecological momentary assessment (EMA). Participants were 355 smokers (33% Caucasian, 33% African American, 32% Latino; 55% female) receiving smoking cessation treatment. Mindfulness was assessed at baseline and on the quit date. For 4 days prequit and 1 week postquit, participants completed up to 4 EMAs per day indicating levels of negative affect (NA), positive affect (PA), smoking urges, and affect regulation expectancies. Mean, slope, and volatility were calculated for each prequit and postquit EMA variable. Associations among mindfulness, EMA parameters, and abstinence on the quit day and 7 days postquit, as well as indirect effects of mindfulness on abstinence through EMA parameters, were examined. Mindfulness predicted higher odds of abstinence in unadjusted but not covariate-adjusted models. Mindfulness predicted lower NA, higher PA, and lower affective volatility. Lower stress mediated the association between mindfulness and quit-day abstinence. Higher ratings of happy and relaxed, and lower ratings of bored, sad, and angry, mediated the association between mindfulness and postquit abstinence. Mindfulness appeared to weaken the association between craving and postquit abstinence. This study elucidates real-time, real-life mechanisms underlying dispositional mindfulness and smoking abstinence. During the early process of quitting smoking, more mindful individuals appeared to have more favorable emotional profiles, which predicted higher likelihood of achieving abstinence 1 week after the quit date. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Evaluating the temporal relationships between withdrawal symptoms and smoking relapse

Smokers attempting to quit often attribute smoking relapse to negative affect, craving, and other nicotine withdrawal symptoms. In addition, there is evidence that smoking relapse can increase these symptoms, particularly negative affect. To address this issue, we analyzed data from an 11-week smoking cessation clinical trial in which smokers (n = 1,246) were randomized to receive either nicotine replacement therapy (NRT), varenicline, or placebo, combined with behavioral counseling. Using cross-lagged analyses, we examined the temporal bidirectional relationships between self-reported measures of affect, craving, and composite withdrawal symptoms and biochemically verified smoking abstinence. The relative strength of these temporal relationships was examined by comparing the explained variances of the models. The results showed that higher negative affect, craving, and composite withdrawal symptoms increased the likelihood of subsequent smoking relapse, and that smoking relapse led to subsequent increases in these same symptoms. A comparison of the explained variances found symptom predicting subsequent relapse models to be stronger than those where relapse predicted subsequent symptoms. Although the explained variance findings generally support a negative reinforcement conceptualization of nicotine dependence, the bidirectional relationship between symptoms and smoking relapse suggests that struggling with quitting smoking leads to significant negative affect, craving, and other withdrawal symptoms that do not quickly resolve. These findings highlight the importance of addressing specific symptoms within the context of smoking cessation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).