Impulsivity and smoking relapse.

Previous research has shown that elevated trait-impulsivity heightens the risk for initiating tobacco use and indicates that nicotine may be disproportionately rewarding for more impulsive persons. However, the influence of impulsivity on the ability to maintain nicotine abstinence has not been studied. The present study tested the hypothesis that a higher level of trait-impulsivity would predict a more rapid relapse to smoking following 48 hr of nicotine abstinence. Participants were euthymic, regular smokers (N=45), with a history of at least one major depressive episode, who participated in a paid smoking cessation study with biological challenge (tryptophan depletion). Treatment involved a 1-day skills training workshop followed by 48 hr of bioverified abstinence and weekly follow-up for 1 month. Regression analyses indicated that elevated impulsivity predicted shorter time to relapse following the workshop after controlling for treatment condition, baseline nicotine dependence, and age (beta=-.39, R(2) change=.147, p=.011). Greater impulsivity predicted more rapid relapse to smoking, which mediational analyses indicated could not be explained by positive affect, negative affect, or craving. Findings suggest a need to identify alternative mechanisms to explain impulsive smokers' increased difficulty in maintaining abstinence and to develop targeted treatments that address the special needs of smokers high in impulsivity.     

Tobacco craving predicts lapse to smoking among adolescent smokers in cessation treatment.

Previous research indicates that tobacco craving predicts relapse to smoking among adult smokers attempting to quit. We hypothesized a similar relationship between craving and lapse (any smoking following a period of abstinence) among adolescent smokers during the treatment phase of a clinical trial. A visit was considered a lapse visit if the participant reported smoking or had a carbon monoxide level of 7 ppm or greater subsequent to an abstinent visit. A total of 34 participants (mean age = 14.9 years [SD = 1.3]; mean cigarettes/day = 18.0 [SD = 7.6]; mean Fagerstr?m Test for Nicotine Dependence score = 6.8 [SD = 1.34]; 65% female), were included in the present analysis of 167 treatment visits. Logistic regression analyses showed a positive relationship between degree of craving, measured by the Questionnaire on Smoking Urges, and lapse during smoking cessation treatment (p = .013). Additionally, linear regression analyses demonstrated a strong positive association between cigarettes smoked per day and craving scores (p<.001). Taken together with other data, these findings suggest that degree of craving might influence tobacco abstinence for adolescent smokers. Thus monitoring and addressing craving appears useful to increase the success of adolescent smoking cessation.     

Severity of nicotine dependence moderates performance on perceptual-motor tests of attention.

Acute abstinence from cigarette smoking by nicotine-dependent smokers has been linked with cognitive deficits, but the role of nicotine dependence per se in these effects is not known. We therefore tested the relationships of nicotine dependence and smoking history with performance in perceptual-motor, timed tests of attention. Nicotine-dependent smokers (n = 37) and nonsmokers (n = 48), 18-55 years old, took both the d2 Test of Attention and the Digit Symbol Test on each of 2 test days. For smokers, testing on one day began after ad libitum smoking (<45 min since last cigarette); and on the other day, it began after overnight abstinence (>13 hr since last cigarette). On each test day, there were two test blocks with an intervening break, when only the smokers each smoked one cigarette. There were no significant effects of abstinence or of smoking one cigarette on the performance of smokers; however, across conditions, the smokers' performance on both tests correlated negatively with severity of nicotine dependence but not lifetime cigarette consumption or cigarette craving. Smokers with high nicotine dependence performed more slowly on both tests than less dependent smokers or nonsmokers. The findings suggest that severity of nicotine dependence and slowness in perceptual-motor tasks of attention share an underlying basis.     

Reactivity to in vivo smoking cues in older adolescent cigarette smokers.

Most smokers initiate smoking in adolescence, and craving for cigarettes may play an important role in maintenance of smoking behavior and relapse to smoking during a quit attempt. Although a significant body of literature explores cue-reactivity in adult smokers, little has been published on cue-reactivity among adolescent smokers. In a previously published work, we found that videotaped smoking cues may not be robust in eliciting craving among adolescent smokers. Hence, in this preliminary study, we examined reactivity to in vivo smoking cues among adolescent smokers (N = 11, average age = 18.1 years, range = 15-19 years, predominantly female). Participants were presented with in vivo smoking and neutral cues (counterbalanced). We recorded subjective craving and real-time heart rate in response to each type of cue. Adolescent smokers had a significantly greater "desire" to smoke (p < .05) in response to smoking cues vs. both baseline and neutral cues. Participants had faster heart rates after the smoking cues during the epochs of 21-30 s and 31-40 s (p values<.05) as compared with baseline, and mean heart rate was higher during the smoking cues relative to neutral cues among participants who received the smoking cues first (p < .05). Results of this preliminary study further demonstrate the feasibility of conducting cue-reactivity studies with adolescent cigarette smokers. Findings from this study suggest that adolescent smokers may show patterns of responding to smoking cues similar to those of adult smokers. Implications for future laboratory studies with adolescent smokers are discussed.     

Menthol cigarettes and smoking cessation during an aided quit attempt.

Menthol may make cigarettes more addictive and rates of menthol cigarette smoking are disproportionately higher among Black. However, few studies have examined the association between menthol cigarette smoking and cessation, and the studies to date have produced conflicting findings. The present study examines the effect of menthol cigarette smoking on cessation among a multi-ethnic sample of smokers making a pharmacotherapy-aided quit attempt. We hypothesized that menthol cigarette smoking would be associated with lower smoking abstinence rates and conducted a secondary analysis of data from a multi-site randomized controlled trial of an intervention designed to facilitate repeat tobacco cessation treatment (N = 1,343). The intervention consisted of a patient phone call and a computerized provider prompt. The primary outcome for this analysis was 7-day point prevalence smoking abstinence. The average age of the sample was 56 years old. Overall, 25% of the sample smoked menthol cigarettes: 19% of Whites, 62% of Blacks, and 25% of other ethnicity (p<.001). We observed no significant effects for menthol cigarette smoking or ethnicity on smoking abstinence rates. In conclusion, combined with findings from previous research, this study suggests that smoking menthol cigarettes does not decrease smoking cessation among older smokers during a quit attempt aided with pharmacotherapy.     

A psychometric evaluation of cigarette stimuli used in a cue reactivity study.

Laboratory studies have demonstrated that cigarette smokers react with significant subjective and autonomic responses (e.g., increased craving and increased heart rate) in the presence of stimuli associated with smoking. Although cue reactivity effects are typically robust, a number of methodological considerations make interpretation and design of cue reactivity studies problematic. Previous research has paid scant attention to the psychometric properties of the cigarette cues presented, and standard cues would enhance comparison and synthesis of studies. In the present study, we evaluated 12 cigarette photos (compared with positive, negative, and neutral photos), used in a separate study, for their ability to evoke self-report of craving in both nicotine-deprived and nondeprived smokers. These photos performed as expected, with cigarette pictures evoking significantly higher craving than neutral pictures and deprived smokers showing a trend toward higher craving than nondeprived smokers. The cigarette picture set was evaluated for internal consistency (Cronbach's alpha = .97) as a 12-item scale and further reduced to multiple 2-item scales with reliability estimates ranging from .70 to .93. A cluster analysis of all pictures showed that, when rated for craving, cigarette pictures clustered together, indicating they had distinct properties compared with positive, negative, and neutral pictures. Effect sizes were calculated for each cigarette picture in both deprived and nondeprived smokers. The craving effect sizes ranged from .57 to .98 for nondeprived smokers, and from .61 to .99 for deprived smokers. The analyses suggest these cigarette pictures have excellent psychometric properties for use in future cue reactivity studies.     

The relationship between cigarette use, nicotine dependence, and craving in laboratory volunteers.

Data from epidemiological studies suggest that individual differences in cigarettes per day (CPD) and duration of smoking account for only a small portion of the variance in Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) nicotine dependence. However, DSM-IV may be an insensitive measure of nicotine dependence; other measures might better reflect the true nature of the relationship between use and dependence. This paper describes the relationship between cigarettes per day (CPD) and years smoking and the severity of nicotine dependence as measured by the Nicotine Dependence Syndrome Scale (NDSS). Furthermore, we assessed the validity of individual differences in nicotine dependence by determining whether they related to cue-evoked craving during abstinence. Data were pooled from five laboratory studies of 489 regular (i.e., 15+ CPD) smokers. In contrast to previously reported data demonstrating a relatively strong relationship between CPD and dependence in chippers (Shiffman & Sayette, 2005), CPD and years smoking accounted for a statistically significant, but small (<6%), portion of the variance in nicotine dependence in daily smokers. Individual differences in both CPD and years smoking had little or no relationship with craving. However, the magnitude of craving was significantly related to the degree of nicotine dependence even after controlling for use variables and excluding craving-related items on the NDSS. These data suggest that among moderate to heavy daily smokers, meaningful individual differences in nicotine dependence are observed independent of differences in current daily cigarette consumption and duration of smoking. Further research into the sources of this variance is critical to understanding the process of and risk for nicotine dependence.     

Characteristics of selectors of nicotine replacement therapy

Objective: To assess differences in demographic and smoking characteristics between smokers who have and have not used nicotine replacement therapy (NRT). Design: Mail survey of US smokers from a national research panel. Participants: Smokers 18 years and over who returned a survey on smoking (n = 9630). The sample was weighted to match the US smoker population on age and sex. Main outcome measures: Compared smokers who had/had not used NRT in a quit attempt (ever NRT use or over the counter (OTC) NRT use) on: demographic characteristics, nicotine dependence, history of craving and withdrawal, expected difficulty quitting, and self reported history of smoking related medical illness and psychopathology. Results: NRT users (both ever-users and OTC users) were more likely to be older, male, and better educated. They were also heavier smokers, had experienced more craving and withdrawal upon quitting, and scored higher on measures of dependence. These differences were evident among light smokers, and remained even when smoking rate and time to first cigarette were controlled. Conclusion: Smokers who elect to use NRT differ from non-NRT users in ways that predispose them to failure in cessation. Controlling for smoking rate and time to first cigarette does not eliminate these differences, even among light smokers. These differences must be considered when comparing the effectiveness of NRT among samples of smokers who self select their treatment and are likely to bias such outcome comparisons.     

Is concern about post-cessation weight gain a barrier to smoking cessation among pregnant women?

Women who quit smoking during pregnancy gain more weight than women who continue to smoke. Concern about weight gain is a barrier to smoking cessation in the general population, but whether attitudes about weight are associated with failure to stop smoking during pregnancy or to maintain abstinence postpartum is unknown. Thus, attitudes about weight were assessed in 412 pregnant smokers recruited from obstetric practices in Massachusetts for a smoking cessation intervention trial. Smoking cessation outcomes (7-day point-prevalence abstinence by self-report and by cotinine-validation) were assessed at end-of-pregnancy and 3 months postpartum. Bivariate and multivariable analyses assessed the relationship between attitudes about weight and smoking cessation. In bivariate analyses, a high level of concern about post-cessation weight gain was associated with older age (p = .01), smoking more cigarettes/day (p<.001), not making a quit attempt in pregnancy (p = .02), being less likely to self-report tobacco abstinence at end of pregnancy (p = .01) and postpartum (p = .02), and having less cotinine-validated abstinence at 3 months postpartum (p = .05). In multivariable analyses that adjusted for cigarettes/day, a low level of concern about post-cessation weight gain was associated with more self-reported abstinence at end-of-pregnancy (OR = 1.77, 95% CI 1.01-3.09) and postpartum (OR = 2.09, 95% CI 1.05-4.14), but not with cotinine-validated abstinence at end-of-pregnancy (OR = 1.30, 95% CI 0.63-2.68) or postpartum (OR = 2.18, 95% CI 0.93-5.10). In conclusion, women who are more concerned about post-cessation weight gain may be less likely to quit smoking during pregnancy or remain abstinent in the postpartum period.     

A self-administered questionnaire to measure cigarette withdrawal symptoms: the Cigarette Withdrawal Scale.

Because few tobacco withdrawal scales have been submitted to appropriate validity analyses, we sought to develop and assess the validity of a new, self-administered scale measuring cigarette withdrawal symptoms. We generated the instrument content by conducting a qualitative survey of 404 smokers and ex-smokers. Then we tested 61 items on the Internet in 3,050 smokers and ex-smokers. Subsamples provided comprehensive retest data after 17 days (n = 1218) and smoking status after 41 days (n = 673). The study resulted in a 21-item, six-dimension scale labeled the Cigarette Withdrawal Scale (CWS-21). The six subscales cover the main components of nicotine or tobacco withdrawal in the Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems and in qualitative data: Depression-anxiety, craving, irritability-impatience, appetite-weight gain, insomnia, and difficulty concentrating. The six scores had a satisfactory test-retest reliability (r = .60-.71) and a high internal consistency (Cronbach's alpha = .83-.96). The factor structure of the scale was robust in a bootstrap resampling procedure. In ex-smokers, all scores except appetite-weight gain and insomnia predicted relapse at 41-day follow-up. In recent ex-smokers who had quit smoking less than 14 days before baseline, all scores except appetite-weight gain decreased between baseline and the 17-day retest. In baseline ex-smokers who relapsed to smoking at the 17-day retest, appetite-weight gain decreased and craving increased between baseline and retest. CWS-21 is a reliable, valid, multidimensional measure of cigarette withdrawal symptoms that is sensitive to change over time and predicts relapse to smoking.     

Smokers' expectancies for nicotine replacement therapy vs. cigarettes.

Smokers (N=188) recruited from the local community completed a questionnaire that measured expected outcomes of using cigarettes, nicotine gum, nicotine patch, and nicotine nasal spray. Expectancy questions relating to negative affect, craving, weight, and health risks were derived from the Smoking Consequences Questionnaire-Adult. As predicted, smokers held much greater expectancies that cigarettes help control negative affect, craving, and weight relative to nicotine replacement therapy (NRT). All NRT products were expected to cause fewer health risks than cigarette smoking. As predicted, smokers held strong negative affect reduction expectancies for cigarette smoking. For NRT, although still relatively low, craving reduction was the strongest expectancy. Individuals who had experience using the nicotine patch had greater positive expectancies for NRT. Greater positive expectancies for NRT were correlated with more immediate plans to quit smoking. In summary, cigarette smokers' positive expectancies about cigarettes do not appear to generalize to NRT products, which may limit their use and effectiveness.     

Cough following initiation of smoking abstinence.

Some clinicians and patients believe that cough and sputum production may transiently increase over the first weeks after smoking cessation and may in fact represent a barrier to successful quitting. The present study described changes in cough after an attempt to quit smoking cigarettes and determined patients' perceptions of how changes in cough affected their ability to maintain abstinence from smoking. Daily smokers already recruited for ongoing outpatient clinical trials of pharmacological aids to quit cigarette smoking were invited to complete self-report questionnaires about their cough for up to 6 weeks after their target quit date (TQD). Of the 176 subjects invited to participate, 112 completed the first assessment after the TQD. Of these, a total of 45 subjects maintained at least 1week of smoking abstinence at some point in the 6-week period (confirmed by carbon monoxide measurements). Two self-report measures found that cough declined steadily in abstinent smokers but was constant in a comparator group of continuing smokers (n = 36). For the 94 subjects who reported smoking at least one cigarette following the TQD, few reported that changes in cough affected their abstinence attempt. For three items asking about this area, the upper 95% confidence interval was no more than 10% for agreement that changes in cough posed any barrier to abstinence. We conclude that an initial increase in cough is unlikely to occur among relatively healthy smokers who stop smoking and that changes in cough do not represent a barrier to maintaining abstinence for most smokers.     

Real-time craving and mood assessments before and after smoking.

This study explored some quandaries concerning craving and mood as motivators to smoke. Craving and negative mood have long been associated with day-to-day smoking as two of the primary motivational forces behind the maintenance of the behavior, as well as significant barriers in smokers' attempts to quit. Craving remains a clinically relevant phenomenon, with most smokers describing craving as a troublesome problem when quitting. Smokers' self-reports of negative mood, as an antecedent for smoking, are so robustly reported that many models of nicotine dependence have incorporated a critical role for negative mood in maintaining smoking behavior. However, several naturalistic studies that collected mood ratings with hand held computers from smokers in real time, just before smoking a cigarette, have provided scant evidence that negative mood plays a major role in motivation to smoke. No study to date has examined craving and mood data as a consequence of smoking, that is, collecting the same data immediately after smoking. This study used personal digital assistants (PDAs) to collect craving and mood data immediately before smoking, immediately after smoking, and at random times of day. Nontreatment seeking smokers (N = 72) carried a PDA for an average of 10 days while they recorded their smoking behavior. Results showed that craving and negative mood ratings were lowest immediately after smoking compared with immediately before smoking and at random times of day. These findings suggest that smokers may be at least partially motivated to smoke to lower their craving and improve their mood states.     

An experimental test of the influence of prior cigarette smoking abstinence on future abstinence.

Significant positive associations between early and later abstinence are often reported in clinical trials on smoking cessation, but those relationships do not permit causal inferences. The present study was conducted to examine experimentally whether prior smoking abstinence histories can directly facilitate later abstinence, using a contingency management procedure to manipulate prior abstinence. A total of 40 adult cigarette smokers who were not trying to quit were randomly assigned to one of two conditions: Contingent ALL (C-ALL), who earned monetary incentives contingent on smoking abstinence during three 5 day experimental periods; or Contingent LAST (C-LAST), who earned incentives independent of abstinence during the first two periods (i.e., noncontingent payments) and contingent on abstinence during the final period. The contingency management procedure was effective in establishing different abstinence histories in the two conditions during the first two periods. Comparison of abstinence levels between the C-ALL and C-LAST conditions during the third period showed significantly greater abstinence in the C-ALL condition, although nicotine withdrawal and other subject ratings generally did not differ significantly between the two conditions. These results provide experimental evidence that prior abstinence histories can directly influence subsequent efforts to abstain from smoking.     

The impact of carotid plaque screening on motivation for smoking cessation.

Showing smokers their own atherosclerotic plaques might increase motivation for smoking cessation, since they underestimate their own risk for smoking-related diseases. To assess the feasibility and optimal processes of studying the impact of carotid atherosclerotic plaque screening in smokers, we enrolled 30 daily cigarette smokers, aged 40-70 years, in an observational pre-post pilot study. All smokers underwent smoking cessation counseling, nicotine replacement therapy, a carotid ultrasound, an educational tutorial on atherosclerosis, baseline and 2-month motivation to change assessment, and assessment of smoking cessation at 2 months. Participants had a mean smoking duration of 34 years (SD = 7). Carotid plaques were present in 22 smokers (73%). Between baseline and 2 months after plaque screening, motivation for smoking cessation increased from 7.4 to 8.4 out of 10 (p = .02), particularly in those with plaques (7.2 to 8.7, p = .008). At 2 months, the smoking quit rate was 63%, with a quit rate of 73% in those with plaques vs. 38% in those without plaques (p = .10). Perceived stress, anxiety, and depression did not increase after screening. 96% of respondents answered correctly at least 80% of questions regarding atherosclerosis knowledge at baseline and after 2 months. In conclusion, studying the process of screening for carotid plaques for the purpose of increasing motivation for smoking cessation, in addition to counseling and drug therapy for smoking cessation in long-term smokers, appears feasible. The impact of carotid plaque screening on smoking cessation should be examined in larger randomized controlled trials with sufficient power to assess the impact on long-term smoking cessation rates.     

Association of post-treatment smoking change with future smoking and cessation efforts among adolescents with psychiatric comorbidity.

Little is known about how initial change following a smoking intervention relates to longer-term smoking outcomes among adolescent smokers with psychiatric comorbidity. The present study investigated this relationship among psychiatrically hospitalized adolescents (N = 183) who participated in a controlled trial comparing motivational interviewing to brief advice. Quit attempters (n = 37), reducers (n = 45), and maintainers (n = 101) were assembled based on, respectively, having made a quit attempt, having reduced smoking by at least 50%, and having reduced smoking by less than 50% in the first week after hospital discharge. Hierarchical linear models and generalized estimating equations were conducted to test group differences in average number of cigarettes per smoking day and odds of making a quit attempt during subsequent weeks of a 12-month continuous follow-up, and in cotinine-verified abstinence rates at 1, 6, and 12 months posthospitalization. Baseline smoking levels and presence of a substance use disorder or anxiety disorder were predictive of outcomes. After controlling for covariates, we found that quit attempters smoked less during follow-up than did the other change groups and that reducers smoked less than maintainers. Quit attempters evidenced a higher percentage of quit attempts during follow-up than did the other change groups. Reducers had a greater average percentage of quit attempts during follow-up than did maintainers. However, groups did not differ on cotinine-verified abstinence rates across the follow-up period. Findings have implications for initial post-treatment change as it relates to subsequent smoking and cessation outcomes among adolescent smokers at especially high risk for smoking persistence.     

A comparison of the Hooked on Nicotine Checklist and the Fagerstr?m Test for Nicotine Dependence in adult smokers.

Diminished autonomy is a core feature common to all forms of dependence involving drugs or behaviors. The Hooked on Nicotine Checklist (HONC) is a reliable and valid measure of diminished autonomy over tobacco. It has not previously been compared with the Fagerstr?m Test for Nicotine Dependence (FTND) in adult smokers. In the present study, 1,130 smokers (M age = 41; M cigs/day = 18.5) completed both measures. Factor analysis yielded one factor for both the HONC and the FTND. Mean HONC score was 7.0, and mean FTND score was 4.6; the measures correlated at r = .44. The HONC had higher internal consistency (alpha = .82) than the FTND (alpha = .61; z(1127) = 7.1, p < .001). The measures correlated similarly with age at smoking onset and days smoked per month, but the FTND correlated higher with cigarette consumption. Subjects who used nicotine replacement therapy or bupropion during an abstinence attempt scored higher on both measures, whereas those who maintained abstinence for at least 3 days scored lower. The HONC has several advantages: (a) It measures a clearly defined construct, and each item has face validity; and it has (b) better psychometric properties, (c) a logical cutpoint (zero symptoms), (d) greater sensitivity to the onset and low levels of dependence, and (e) easily interpretable scores. The HONC is uniquely suited for use with smokers whose cigarette consumption is low.     

Ad lib smoking in post-traumatic stress disorder: an electronic diary study

Using ambulatory methods for 1 week of monitoring, this study investigated the association between smoking and situational cues in 22 smokers with post-traumatic stress disorder (PTSD) and 23 smokers without PTSD. Generalized estimating equations contrasted 1,759 smoking and 1,088 nonsmoking situations by group status controlling for multiple covariates. PTSD smokers reported higher stress and PTSD symptoms across daily activities. For all smokers, higher nicotine dependence, craving, food and caffeine consumption, and being outside were related to smoking. PTSD smokers were more likely to smoke when experiencing PTSD symptoms, anxiety, and stress. Following smoking, smokers with PTSD reported a significant reduction in negative affect. These results are consistent with previous ambulatory findings regarding mood in smokers, and underscore that in smokers with PTSD, PTSD symptom variables as well as stress and anxiety are significantly associated with ad lib smoking.     

Comparison of cigarette and water pipe smoking among female university students in Egypt.

This study investigated behavioral and sociodemographic factors associated with tobacco use among female university students patronizing water pipe cafes in Cairo, Egypt. We interviewed two groups of female university student smokers (100 and 96 students from a public and a private university, respectively). The interviews took place in nine water pipe cafes near the two universities. A logistic regression model was developed to analyze the relationship between tobacco-related knowledge and beliefs and the choice between smoking water pipe or cigarettes. Among these smokers, 27% smoked cigarettes only, 37.8% smoked water pipe only, and 35.2% smoked both types of tobacco. Most of the water pipe smokers (74.1%) preferred this method because they believe it to be less harmful than smoking cigarettes. More than half of the subjects were encouraged to start smoking by other females (56.6%). Curiosity was a significant factor for initiation (OR = 2.8, 95% CI = 1.3-6.2, p<.01). We found no significant differences between water pipe and cigarette smokers regarding current age, age at initiation, quit attempts, knowledge about the hazards of smoking, wanting to be fashionable, or smoking with friends. About one in four (23.7%) attempted to quit, with health cited as a major reason. An urgent need exists for correction of the misperception among this study population that water pipe smoking is safe and less harmful than cigarette smoking.