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 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)     

Transdermal nicotine: The long and the short of it.

Cigarette smokers with a mean history of 35 smoking years (N?=?98) were randomly assigned to receive either 3 weeks or 12 weeks of transdermal nicotine treatment combined with a 5-session behavioral management program. Participants were followed for 20 weeks. At the conclusion of the study, 26% of the 3-week participants and 29% of the 12-week participants were abstinent. The number of abstinent participants and duration of abstinence were not significantly different between the 2 groups, although statistical power constraints do not rule out the possibility of small undetected differences in outcome. Most participants (68%) smoked at least once during their nicotine patch regimen. Smoking on the patch was associated with poor outcome. Those who smoked while using the patch reported more restlessness and cigarette cravings and lower confidence and intention to quit smoking than did participants who did not smoke during the drug regimen. (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)     

Both Smoking Reduction With Nicotine Replacement Therapy and Motivational Advice Increase Future Cessation Among Smokers Unmotivated to Quit.

Smokers not currently interested in quitting (N=616) were randomized to receive telephone-based (a) reduction counseling plus nicotine replacement therapy (NRT) plus brief advice to quit, (b) motivational advice plus brief advice, or (c) no treatment. More smokers in the reduction (43%) and motivational (51%) conditions made a 24-hr quit attempt over 6 months than smokers in the no-treatment condition (16%; p ≤ .01), but the 2 active conditions did not differ (p ≥ .05). Similarly, 18%, 23%, and 4% of each condition were abstinent (7-day point prevalence) at 6 months (p ≤ .01). Results indicate smoking reduction using NRT does not undermine cessation but rather increases the likelihood of quitting to a degree similar to motivational advice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concurrent brief versus intensive smoking intervention during alcohol dependence treatment.

Alcohol dependent smokers (N=118) enrolled in an intensive outpatient substance abuse treatment program were randomized to a concurrent brief or intensive smoking cessation intervention. Brief treatment consisted of a 15-min counseling session with 5 min of follow-up. Intensive intervention consisted of three 1-hr counseling sessions plus 8 weeks of nicotine patch therapy. The cigarette abstinence rate, verified by breath carbon monoxide, was significantly higher for the intensive treatment group (27.5%) versus the rate for the brief treatment group (6.6%) at 1 month after the quit date but not at 6 months, when abstinence rates fell to 9.1% for the intensive treatment group and 2.1% for the brief treatment group. Smoking treatment assignment did not significantly impact alcohol outcomes. Although intensive smoking treatment was associated with higher rates of short-term tobacco abstinence, other, perhaps more intensive, smoking interventions are needed to produce lasting smoking cessation in alcohol dependent smokers. (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)     

Comparing gain- and loss-framed messages for smoking cessation with sustained-release bupropion: A randomized controlled trial.

Prospect theory suggests that because smoking cessation is a prevention behavior with a fairly certain outcome, gain-framed messages will be more persuasive than loss-framed messages when attempting to encourage smoking cessation. To test this hypothesis, the authors randomly assigned participants (N=258) in a clinical trial to either a gain- or loss-framed condition, in which they received factually equivalent video and printed messages encouraging smoking cessation that emphasized either the benefits of quitting (gains) or the costs of continuing to smoke (losses), respectively. All participants received open label sustained-release bupropion (300 mg/day) for 7 weeks. In the intent-to-treat analysis, the difference between the experimental groups by either point prevalence or continuous abstinence was not statistically significant. Among 170 treatment completers, however, a significantly higher proportion of participants were continuously abstinent in the gain-framed condition as compared with the loss-framed condition. These data suggest that gain-framed messages may be more persuasive than loss-framed messages in promoting early success in smoking cessation for participants who are engaged in treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between in-treatment abstinence and post-treatment abstinence in a smoking cessation treatment.

Previous research has indicated that abstinence early in a smoking cessation program is predictive of successful posttreatment abstinence. However, it has not been established whether or not this effect is independent of other in-treatment abstinence patterns. In this paper the relationship between three potentially important aspects of in-treatment smoking abstinence and posttreatment smoking abstinence are examined: early abstinence, extended abstinence, and end-of-treatment abstinence. We examined the relationship between smoking behavior measured each weekday over 70 visits (approximately 14 weeks) of a contingency management smoking cessation program and at a follow-up visit 6 months after study entry (3 months after the scheduled end of treatment). Ninety-five of 102 participants were successfully followed-up. Seven of these 95 participants were confirmed abstinent. Early abstinence, defined as abstinence during the first 10 treatment visits, was significantly and independently related to follow-up abstinence (OR = 56.67 [7.29–440.63]). Extended abstinence and end-of-treatment abstinence were related to follow-up abstinence, but not independent of early abstinence based on multiple regression models. Inclusion of a variety of demographic and environmental characteristics did not significantly alter this relationship. Thus, consistent with the previous literature, the establishment of early abstinence appears to be crucial to establishing longer-term abstinence, independent of other in-treatment abstinence patterns. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized clinical trial of a palmtop computer-delivered treatment for smoking relapse prevention among women.

Relapse is the rule rather than the exception among smokers attempting to quit, and compared to men, women may have higher relapse rates. The current study was a randomized clinical trial testing a palmtop computer-delivered treatment (CDT) for smoking relapse prevention among women. The intervention was individualized based on key theoretical constructs that were measured using ecological momentary assessment (EMA). All participants (N = 302) received standard smoking cessation treatment consisting of nicotine replacement therapy and group counseling, and completed EMA procedures for one week after quitting. At the completion of the group counseling sessions and EMA procedures, participants were randomized to either CDT or no further computer-delivered treatment or assessment (EMA-Only). CDT participants received a palmtop computer-delivered relapse prevention treatment for one additional month. CDT did not improve abstinence rates relative to EMA-Only. Process analyses suggested that heavier smokers were more likely to use CDT and that greater use among CDT participants may be associated with more positive outcomes. The rapid pace of technological advances in mobile computer technology and the ubiquity of such devices provide a novel platform for developing new and potentially innovative treatments. However, the current study did not demonstrate the efficacy of such technology in improving treatment outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Motivating Latino caregivers of children with asthma to quit smoking: A randomized trial.

Objective: Secondhand smoke exposure is associated with asthma onset and exacerbation. Latino children have higher rates of asthma morbidity than other groups. The current study compared the effectiveness of a newly developed smoking cessation treatment with existing clinical guidelines for smoking cessation. Method: Latino caregivers who smoked (N = 133; 72.9% female; mean age = 36.8 years) and had a child with asthma were randomly assigned to receive 1 of 2 smoking cessation counseling interventions during a home-based asthma program: (a) behavioral action model (BAM; modeled on clinical guidelines for smoking cessation) or (b) precaution adoption model (PAM; feedback on the caregiver’s carbon monoxide level and child’s secondhand smoke exposure using Motivational Interviewing). Counseling was delivered by a bilingual Latina health educator, and the content was tailored to Latino values and culture. It was not necessary for smokers to want to quit smoking to participate. Smoking cessation was biochemically verified and secondhand smoke exposure was objectively measured through passive nicotine monitors. Results: Intent-to-treat analyses showed that 20.5% of participants in the PAM condition and 9.1% of those in the BAM condition were continuously abstinent at 2 months posttreatment (OR = 2.54; 95% CI = 0.91–7.10), whereas 19.1% of participants in the PAM condition and 12.3% of those in BAM condition were continuously abstinent at 3 months posttreatment (OR = 1.68; 95% CI = 0.64–4.37). Secondhand smoke exposure decreased only in the BAM condition (p p     

Situational Correlates of Abstinence Self-Efficacy.

Little is known about the situations that are associated with changes in self-efficacy during an attempt to quit smoking. In this study, 214 smokers used palmtop computers to record momentary self-efficacy ratings and situational context during a quit attempt. Higher urge to smoke and negative affect were associated with reduced self-efficacy. Although alcohol and coffee consumption are associated with heightened lapse risk, they were unrelated to abstinence self-efficacy. Individuals with low baseline self-efficacy generally reported lower self-efficacy across situations, but these differences were more pronounced under conditions of high urge and negative affect. These results suggest that self-efficacy may be reactive to affect-motivational states during a quit attempt. Whether these influences represent cognitive biases or objective risk assessments is not known. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beliefs and attitudes about bupropion: Implications for medication adherence and smoking cessation treatment.

Beliefs about medication are associated with treatment adherence and outcome. This is a secondary analysis of the role of beliefs and attitudes about bupropion in treatment adherence and smoking cessation outcomes using data from a smoking cessation trial of open-label sustained-release (SR) bupropion therapy reported previously (Toll et al., 2007). Positive beliefs and attitudes were positively correlated with intentions, desire, confidence, and motivation to quit smoking; expectation of quitting success; perceived benefits of quitting; and perceived disadvantages of smoking. Positive beliefs were also associated with greater medication adherence, an increased likelihood of completing treatment and being continuously abstinent, and a delayed latency to smoking lapse. These findings provide preliminary support that positive beliefs and attitudes about bupropion are associated with positive attitudes toward quitting, better treatment adherence, and potentially better treatment response. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Distress tolerance and duration of past smoking cessation attempts.

The present study tested the hypothesis that limited ability to tolerate physical and psychological distress is associated with early relapse from smoking cessation. Specifically, the authors exposed 16 current smokers who had failed to sustain any previous quit attempt for more than 24 hr (immediate relapsers) and 16 smokers with at least 1 sustained quit attempt of 3 months or longer (delayed relapsers) to psychological (mental arithmetic) and physical (carbon dioxide inhalation-breath holding) stressors. Relative to delayed relapsers, immediate relapsers were characterized by higher baseline levels of affective vulnerability, by greater levels of dysphoria and urge to smoke after 12 hr of nicotine deprivation, and by less task persistence on the stressors, suggesting that these may be risk factors for early lapse in the context of quitting smoking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparing intervention outcomes in smokers treated for single versus multiple behavioral risks.

This study examined treatment outcomes among smokers with single versus multiple behavioral risks. Data were drawn from smokers (N = 2,326) participating in 3 population-based, multibehavioral studies targeting cigarette smoking, high-fat diets, and high-risk sun exposure. Outcomes were compared for participants at risk for smoking only (13%), smoking plus 1 additional risk factor (37%), and smoking plus 2 additional risk factors (50%). The smoking only group tended to be female, older, more educated, lighter smokers, in the preparation stage of change for smoking, with more previous quit attempts and longer periods of abstinence. At 12 and 24 months follow-up, treatment of 1 or 2 coexisting risk factors did not decrease the effectiveness of smoking cessation treatment, and treatment for the coexisting factors was effective. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Characteristics of Air Force personnel who choose pharmacological aids for smoking cessation following an involuntary tobacco ban and tobacco control program.

Objective: The objective of this study was to compare characteristics of smokers who did and did not report use of cessation aids as part of a tobacco control program in a military setting (n = 8994). Design: The study is a longitudinal epidemiological study where the relationship between smoking status at follow-up and use of pharmacologic aids to quit smoking were assessed. Main Outcome Measures: Smoking cessation, post baseline use of cessation aids to quit smoking. Results and Conclusions: Individuals remaining abstinent were 70% less likely to have used NRT/pharmacological aids compared to those that relapsed. NRT/pharmacological aid users were more likely to report plans to smoke after military training, to have friends who smoke, and to accept a cigarette from a friend. NRT/pharmacological aid users were more likely to believe that using NRT was safer than smoking and to have engaged in harm reduction strategies. Our findings suggest that selection bias related to such characteristics may explain some of the discrepancies between effect sizes reported in efficacy compared to effectiveness studies of NRT and smoking outcomes currently reported in the literature. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How much weight gain occurs following smoking cessation: A comparison of weight gain using both continuous and point prevalence abstinence.

Estimates of postcessation weight vary widely. This study determined the magnitude of weight gain in a cohort using point prevalence and continuous abstinence criteria for cessation. Participants were 196 volunteers who participated in a smoking cessation program and who either continuously smoked (n?=?118), were continuously abstinent (n?=?51), or who were point prevalence abstinent (n?=?27) (i.e., quit at the 1-year follow-up visit but not at others). Continuously abstinent participants gained over 13 lbs. (5.90 kg) at 1 year, significantly more than continuously smoking (M?=?2.4 lb.) and point prevalence abstinent participants (M?=?6.7 lbs., or 3.04 kg). Individual growth curve analysis confirmed that weight gain and the rate of weight gain (pounds per month) were greater among continuously smoking participants and that these effects were independent of gender, baseline weight, smoking and dieting history, age, and education. Results suggest that studies using point prevalence abstinence to estimate postcessation weight gain may be understanding postcessation weight gain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral treatment for smokers with a history of alcoholism: Predictors of successful outcome.

This study examined baseline predictors associated with smoking abstinence among 205 smokers (113 men, 92 women) with a past history of alcoholism. Their mean age was 41.8 years, and 93% were Caucasian. Participants were randomly assigned to standard treatment (ST), behavioral counseling plus exercise (BEX), or behavioral counseling plus nicotine gum (BNIC). Factors multivariately associated with point-prevalence smoking abstinence at posttreatment (1 week after target quit date) were a longer duration of prior smoking abstinence and an interaction between treatment group and having an active 12-step sponsor. ST was more effective for those with an active sponsor, whereas both BEX and BNIC were more effective for those without an active sponsor. At 1-year follow-up, independent predictors of point-prevalence smoking abstinence were a lower Fagerstr6m Tolerance Questionnaire score (K. O. Fagerstrom, 1978) and fewer years of smoking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Using SMS text messaging to assess moderators of smoking reduction: Validating a new tool for ecological measurement of health behaviors.

Objective: Understanding the psychological processes that contribute to smoking reduction will yield population health benefits. Negative mood may moderate smoking lapse during cessation, but this relationship has been difficult to measure in ongoing daily experience. We used a novel form of ecological momentary assessment to test a self-control model of negative mood and craving leading to smoking lapse. Design: We validated short message service (SMS) text as a user-friendly and low-cost option for ecologically measuring real-time health behaviors. We sent text messages to cigarette smokers attempting to quit eight times daily for the first 21 days of cessation (N-obs = 3,811). Main outcome measures: Approximately every two hours, we assessed cigarette count, mood, and cravings, and examined between- and within-day patterns and time-lagged relationships among these variables. Exhaled carbon monoxide was assessed pre- and posttreatment. Results: Negative mood and craving predicted smoking two hours later, but craving mediated the mood–smoking relationship. Also, this mediation relationship predicted smoking over the next two, but not four, hours. Conclusion: Results clarify conflicting previous findings on the relation between affect and smoking, validate a new low-cost and user-friendly method for collecting fine-grained health behavior assessments, and emphasize the importance of rapid, real-time measurement of smoking moderators. (PsycINFO Database Record (c) 2011 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)