Effect of high-dose nicotine patch on the characteristics of lapse episodes.

Objective: Nicotine patch improves treatment outcomes, but lapses are still common. To understand the process of relapse on patch, we investigated differences in the antecedents (withdrawal, setting, triggers) of lapse episodes experienced on high-dose (35 mg) nicotine patches versus placebo. Design: Participants were smokers who lapsed during a randomized, double-blind trial of active patches (n = 100) versus placebo (n = 85). Participants used electronic diaries to monitor their smoking, affect, and activities in real time for 5 weeks during their cessation attempt. Results: We analyzed 490 lapse episodes (active: 266; placebo: 224). Lapses on nicotine patch were characterized by significantly lower positive affect and higher negative affect than placebo lapses. Participants treated with high-dose patch were also significantly more likely to lapse in situations involving little or no craving. Situational antecedents of lapses on patch resembled those on placebo. Conclusion: The results suggest that treatment with patch may set a higher threshold for affective stimuli to provoke lapses, but does not change the proximal cues that trigger lapses. This suggests that behavioral relapse-prevention strategies developed for unmedicated smokers should also apply to those treated with nicotine patch. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lapse-induced surges in craving influence relapse in adult smokers: An experimental investigation.

Objectives: Nearly all smokers who lapse experience a full-blown relapse, but the mediating mechanisms that contribute to this relationship are not well understood. A better understanding of these mechanisms would help to advance more effective relapse prevention treatments for smokers. The purpose of this study is to experimentally evaluate the effects of a programmed smoking lapse on smoking relapse and the effects of postlapse changes in craving on relapse. Method: Adult smokers (n = 63) who quit smoking with a brief cognitive–behavioral intervention and self-help materials were randomly assigned to one of two experimental conditions after 48 h of abstinence: No lapse (a no-smoking control/30-min waiting period) or lapse (smoking two cigarettes of their favored brand during a 30-min period). All participants were then followed daily for 14 days. Craving and biochemically verified self-reported abstinence were assessed on each follow-up day. Time (days) to relapse (7 consecutive days of smoking) was the main dependent measure. Results: Results of Cox regression analysis revealed that participants in the lapse condition relapsed more quickly than participants in the no-lapse condition (hazard ratio [HR] = 2.12, 95% confidence interval [CI] = [1.03, 4.35]). These effects were attributable, in part, to episodic increases in craving among participants in the lapse condition only (HR = 12.42, 95% CI =[2.00, 77.1]). Conclusions: Previously abstinent smokers who lapse are at risk for increased cigarette cravings and consequently, full-blown relapse. These results have implications for both cognitive–behavioral treatments for relapse prevention and for medications designed to help smokers manage cravings. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Dynamic effects of self-efficacy on smoking lapse and relapse.

Self-efficacy (SE) is thought to be critical to success in smoking cessation both as an individual difference and as a dynamic process after a quit attempt. In this study, 214 smokers used palm-top computers to record day-to-day variations in SE during 4 weeks after quitting. SE remained at high and stable levels prior to a 1st lapse but decreased and became more variable thereafter. The authors used event history models with time-varying covariates to assess the effect of daily SE on lapse and relapse risk. Daily SE measures predicted an initial lapse on the subsequent day. However, this relationship was accounted for by stable baseline differences in SE (assessed by questionnaire), rather than by day-to-day dynamics in SE. Progression from 1st lapse to relapse was also examined. In this instance, daily SE predicted subsequent relapse risk, even when baseline SE and concurrent smoking were accounted for, suggesting the importance of SE dynamics for this stage of the relapse process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Experimental evidence for a causal relationship between smoking lapse and relapse.

In this study, the authors prospectively evaluated the impact of a smoking lapse on relapse probability. After 4 days of smoking abstinence, 60 smokers were randomly assigned to smoke 5 nicotine-containing or 5 denicotinized cigarettes, or to remain abstinent (no lapse) during a 4-hr time period. Afterward, smoking abstinence was encouraged with monetary incentives, and smoking behavior was tracked for 6 days. Relative to the no-lapse condition, exposure to either of the cigarette types more than doubled the probability of subsequent smoking. Smoking outcomes did not differ between nicotine-containing and denicotinized cigarettes. The data suggest that stimulus factors may play an important role in lapse to relapse processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dynamic effects of self-efficacy on smoking lapses and relapse among adolescents.

Objective: The present study examined whether dynamic day-to-day variations in self-efficacy predicted success in quit attempts among daily smoking adolescents. Design: A sample of 149 adolescents recorded their smoking and self-efficacy three times per day during 1 week prior to and 3 weeks after a quit attempt. Main Outcome Measures: The first lapse, second lapse, and relapse after at least 24 hours of abstinence from smoking were the main outcome measures. Results: Self-efficacy was relatively high and moderately variable prior to the first lapse, but decreased and became more variable thereafter. Lower self-efficacy as measured at the lapse assessment significantly increased the risk that a second lapse and relapse would occur. Individual differences in baseline self-efficacy did not predict any of the treatment outcomes. The time-varying analyses, however, showed that lower self-efficacy on a given day predicted the first lapse, the second lapse, and relapse on the succeeding day. Daily concomitant smoking (any smoking on the preceding day) was not significantly related to relapse. Conclusion: The present results emphasize the importance of self-efficacy among adolescents in cessation and highlight the need for dynamic formulations and assessments of adolescents' self-efficacy and relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A preliminary investigation of rapid smoking as a lapse-responsive treatment for tobacco dependence.

Lapses within the first 2 weeks of a smoking cessation attempt are strongly associated with a return to regular smoking (S. L. Kenford et al., 1994). Unfortunately, little is known about how to prevent an initial lapse from progressing to a full relapse, and presently there are no validated lapse-responsive therapeutic interventions. The present study tested the efficacy and feasibility of rapid smoking plus counseling as a novel lapse-responsive intervention. Sixty-seven participants enrolled in a smoking treatment program involving brief counseling and a 9-week course of bupropion. Beginning on the quit day, participants' smoking behavior was tracked daily for 14 days. Once an early smoking lapse was identified, participants were randomly assigned to receive either 3 sessions of rapid smoking plus counseling or no intervention (usual care). Consistent with previous research, participants who smoked during the first 2 weeks of the quit attempt had significantly poorer 6-month outcomes (3% abstinent) than did those who did not smoke (64% abstinent). Compared with early abstainers, early lapsers were more nicotine dependent and reported greater cravings and lower confidence in their ability to abstain from smoking during the first 48 hours of abstinence. As expected, rapid smoking produced a variety of aversive effects, including increased nausea, dizziness, and vomiting as well as sharply decreased cravings to smoke. However, rapid smoking did not improve abstinence outcomes relative to usual care. Although rapid smoking has been shown to be an effective treatment for initial smoking cessation, in this preliminary study the authors failed to demonstrate its effectiveness as a lapse-responsive treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Resisting temptations to smoke: Results from within-subjects analyses.

Within-subjects analyses were used to examine differences between resisted temptations to smoke (either a specific close call or the most common temptation) and smoking lapses among 130 participants lapsing within 1 month after a self-initiated quit attempt. Participants were more likely to report coping during resisted temptations than during lapses; those who reported coping in both were more likely to report using multiple strategies and combining cognitive and behavioral strategies during the resisted temptation. Participants were more likely to report that the lapse was precipitated by others smoking, but this difference was not significant when the sample was restricted to those reporting a specific close call. No other statistically significant differences were found. Results support previous findings that the use or nonuse of coping strategies during a temptation to smoke is the variable most strongly associated with its outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A day at a time: Predicting smoking lapse from daily urge.

Smokers who recently quit (N?=?214) monitored smoking urges for up to 26 days after quitting. Computers administered 4–5 assessments daily at random times; participants rated urges on waking and when they experienced temptation episodes. Urge intensity after cessation did not generally exceed urges reported during baseline ad lib smoking. Urge intensity and temptation frequency consistently declined over the quit period. Controlling for urge intensity at baseline, all daily urge intensity measures predicted lapse the following day in proportional hazards survival analyses. Average duration of temptation episodes also predicted lapses; frequency of temptation did not. To isolate the effect of day-to-day variations in urges, participants' nicotine dependence and urge intensity on quit day were controlled for. Only urge intensity at waking still predicted lapse risk; this was not because of this measure being closer in time to the day's lapses. Among lapsers, urge intensity at waking and in temptations rose preceding a lapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Temptations to smoke after quitting: A comparison of lapsers and maintainers.

This study addresses whether characteristics of temptations to smoke differ for participants who quit smoking and maintain abstinence compared to those who quit and then lapse. Participants used hand-held computers to record temptations and were beeped at random for base-rate assessments. We used generalized estimating equations to compare 1,851 temptation episodes and 5,192 random assessments recorded by 151 participants (116 lapsers, 35 maintainers) over 1–23 days of abstinence. Compared to randomly sampled occasions, temptations were marked by greater negative affect, restlessness, attention disturbance, and exposure to smoking cues; participants were also more likely to be eating or drinking during temptations. Temptations reported by lapsers and maintainers did not differ in any respect, including their reported coping. The results highlight situational variance over individual differences. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Dynamic Self-Efficacy and Outcome Expectancies: Prediction of Smoking Lapse and Relapse.

According to social learning models of drug relapse, decreases in abstinence self-efficacy (ASE) and increases in positive smoking outcome expectancies (POEs) should foreshadow lapses and relapse. In this study, the authors examined this hypothesis by using ecological momentary assessment data from 305 smokers who achieved initial abstinence from smoking and monitored their smoking and their ASE and POEs by using palmtop computers. Daily ASE and POEs predicted the occurrence of a 1st lapse on the following day. Following a lapse, variations in daily ASE predicted the onset of relapse, even after controlling for concurrent smoking. ASE and POEs generally neither mediated nor moderated each other's effects. These data emphasize the role of dynamic factors in the relapse process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Smoking withdrawal dynamics: II. Improved tests of withdrawal-relapse relations.

In this article, the authors assessed whether continuously scaled symptom parameters derived from growth models (T. M. Piasecki et al., 2003) are linked to smoking at long-term follow-up by using data from a large-scale clinical trial (N=893). Results revealed that higher withdrawal intercepts, positive linear slopes, and greater volatility were all positively associated with relapse, and cigarette coefficients (indicating smoking-induced withdrawal reduction) were negatively related to relapse. In models keyed around the first lapse to smoking, those destined to lapse reported more severe withdrawal during abstinence, and withdrawal patterns discriminated groups defined according to lapse duration. The findings complement earlier heterogeneity studies in implicating the pattern of changing withdrawal symptoms over time as a factor strongly associated with smoking relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-efficacy for recovery from a lapse after smoking cessation.

Self-efficacy for avoiding any lapse after smoking cessation has often been found to predict maintaining abstinence. The authors measured recent ex-smokers' self-efficacy for recovery of abstinence (SER) after an initial lapse by using the articulated thoughts during simulated situations (G. C. Davison et al, 1983) paradigm. Ss with moderate SER maintained abstinence nonsignificantly longer than did those with high SER, significantly longer than those with low SER. This result is consistent with A. Bandura's (1986) hypothesis that SER should be high enough that ex-smokers do not become hopeless if a lapse occurs, yet not so high that they are tempted to experiment with smoking. The discussion focuses on measurement and conceptualization of SER, in particular its distinctiveness from response–outcome expectations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Remember that? A comparison of real-time versus retrospective recall of smoking lapses.

Research and treatment assessments often rely on retrospective recall of events. The accuracy of recall was tested using accounts of smoking relapse episodes from 127 participants who had quit smoking, and lapses and temptations were recorded in near-real time using a hand-held computer. These computer records were compared with retrospective accounts elicited 12 weeks later, with a focus on recall of lapses in 4 content domains: mood, activity, episode Triggers, and abstinence violation effects. Recall of lapses was quite poor: Average kappas for items ranged from 0.18 to 0.27. Mean profile rs assessing recall for the overall pattern of behavior were .36, .30, .33, and .44 for these domains, respectively. In recall, participants overestimated their negative affect and the number of cigarettes they had smoked during the lapse, and their recall was influenced by current smoking status. The findings suggest caution in the use of recall in research and intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Analyzing milestones in smoking cessation: Illustration in a nicotine patch trial in adult smokers.

Tests of addiction treatments seldom reveal where treatment exercises its effect (i.e., promoting initial abstinence, preventing lapses, and/or impeding progression from lapse to relapse). The authors illustrate analyses distinguishing effects on these milestones in a randomized trial of high-dose nicotine patch (35 mg; n = 188) versus placebo (n = 136) in adult smokers, who used electronic diaries to monitor smoking in real time during 5 weeks of treatment. High-dose patch promoted initial abstinence (hazard ratio [HR] = 1.3) and decreased the risk of lapsing among those who achieved abstinence (HR = 1.6). The biggest effect of treatment was to prevent progression to relapse among those who had lapsed (HR = 7.1). Analysis of effects by milestones may enhance understanding of cessation treatments and their mechanisms of action. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Drinking trajectories following an initial lapse.

Relapse following alcohol treatment is a major problem for individuals who are alcohol dependent, yet little is known about the course of drinking after the initial lapse. In the current study, discrete-time survival analysis and latent growth mixture modeling were used to evaluate the time to first lapse and the trajectories of postlapse drinking in a sample of 563 individuals who received community alcohol treatment. Results showed a decreasing risk of lapsing over time. After the initial lapse, 3 trajectory subgroups provided a parsimonious representation of the heterogeneity in postlapse drinking frequency and quantity, with the majority of individuals reporting light, infrequent drinking. Covariate analyses incorporating demographics, distal risk factors, time to first lapse, and coping behavior as predictors of time to lapse and postlapse drinking trajectories indicated that alcohol dependence and coping behavior were the strongest predictors of lapsing and postlapse drinking behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prediction of smoking relapse: Analyses of temptations and transgressions after initial cessation.

Different types of "relapse crises" and associated coping responses were associated with the resumption of smoking using a prospective design. One hundred and two previously heavy smokers (M?=?23.9 cigarettes a day) who achieved initial abstinence through a smoking cessation program were interviewed by telephone at 1, 2, and 3 months posttreatment. At each assessment, subjects described relapse crises, situations in which they were tempted to smoke or actually smoked but resumed abstinence (lapsed). Prospective analyses indicated that any smoking lapse is strongly related to subsequent relapse. Situational characteristics of relapse crises and the number of cognitive and behavioral coping responses reported during crises were only modestly consistent over time and were unrelated to later relapse. Confidence ratings and situational attributions about the relapse crises were also not prospectively associated with eventual relapse. Subanalyses suggested that lapses associated with urges and emotional (guilt) responses and lapses occurring in frequent situations are more likely to result in relapse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of five smoking cessation pharmacotherapies on smoking cessation milestones.

Objective: Most smoking cessation studies have used long-term abstinence as their primary outcome measure. Recent research has suggested that long-term abstinence may be an insensitive index of important smoking cessation mechanisms. The goal of the current study was to examine the effects of 5 smoking cessation pharmacotherapies using Shiffman et al.'s (2006) approach of examining the effect of smoking cessation medications on 3 process markers of cessation or smoking cessation milestones: initial abstinence, lapse, and the lapse–relapse transition. Method: The current study (N = 1,504; 58.2% female and 41.8% male; 83.9% Caucasian, 13.6% African American, 2.5% other races) examined the effect of 5 smoking cessation pharmacotherapy treatments versus placebo (bupropion, nicotine lozenge, nicotine patch, bupropion + lozenge, patch + lozenge) on Shiffman et al.'s smoking cessation milestones over 8 weeks following a quit attempt. Results: Results show that all 5 medication conditions decreased rates of failure to achieve initial abstinence and most (with the exception of the nicotine lozenge) decreased lapse risk; however, only the nicotine patch and bupropion + lozenge conditions affected the lapse–relapse transition. Conclusions: These findings demonstrate that medications are effective at aiding initial abstinence and decreasing lapse risk but that they generally do not decrease relapse risk following a lapse. The analysis of cessation milestones sheds light on important impediments to long-term smoking abstinence, suggests potential mechanisms of action of smoking cessation pharmacotherapies, and identifies targets for future treatment development. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transitions During Effective Treatment for Cocaine-Abusing Homeless Persons: Establishing Abstinence, Lapse, and Relapse, and Reestablishing Abstinence.

Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the manner in which drug use changes as a result of abstinent-contingent housing and work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

First lapses to smoking: Within-subjects analysis of real-time reports.

Studies of smoking relapse and temptation episodes have relied on retrospective recall and confounded between- and within-subject variability. Real-time data on temptations and lapses to smoke were gathered using palm-top computers. We made within-subject comparisons of the initial lapse, a temptation episode, and base rate data obtained through randomly scheduled assessments. Negative affect discriminated all three situations, with lapses worse than temptations, and temptations worse than random situations. Participants attributed lapses to negative mood and smoking cues, whereas temptations were more often attributed to behavioral transitions. Participants were 12 times more likely to report coping in temptations than in lapses. However, only cognitive ( vs. behavioral ) coping strategies were effective. Lapses (vs. the other situations) were more likely to occur when smoking was permitted, when cigarettes were easily available, and in the presence of other smokers. The results have clinical implications, and the computerized monitoring methods may be applicable to an array of clinical research problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment of coping with high-risk situations for exercise relapse among healthy women.

29 healthy women's coping responses to situations interfering with planned exercise and subsequent patterns of relapse were evaluated. Participants adopted exercise without formal intervention; their activity was monitored prospectively for 14 wks. Cardiovascular fitness was assessed at baseline, 3 mo, and 9 mo. A 1-wk exercise activity lapse was experienced by 66% of participants, and 41% experienced a 3-wk relapse episode. Relapsers initially reported significantly fewer behavioral and cognitive coping strategies in response to high-risk situations compared with nonrelapsers, controlling for baseline level of self-motivation. Coping responses also predicted short-term fitness. These data demonstrate the importance of coping or problem-solving ability in exercise and suggest that relapse may result from ineffective coping with exercise barriers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)