Attentional bias training and cue reactivity in cigarette smokers

Aims Attentional bias for drug‐related cues has been associated with drug maintenance and relapse. We investigated whether attentional bias for smoking‐related stimuli could be altered using a modified visual probe task in cigarette smokers. We also sought to determine whether changes in attentional bias were associated with changes in subsequent craving and cue reactivity. Participants Male and female (n = 54) current smokers (≥5 cigarettes per day), aged between 18 and 40 years, were recruited from staff and students of the University of Bristol, and from the general population. Design Participants attended a single test session and completed an attentional training procedure in which they were either trained to attend to smoking‐related pictorial stimuli (attend group) or to neutral pictorial stimuli (avoid group). Group allocation was randomized. Measurements Following attentional training, participants underwent a smoking cue exposure procedure in which they were exposed to smoking‐related stimuli. Subjective measures of mood and craving were taken at baseline and before and after cue exposure. Participants then smoked a cigarette and smoking topography was measured. Findings Attentional training increased attentional bias among participants in the attend group, and decreased attentional bias among those in the avoid group. There were also differences between the attend and avoid groups in post‐training changes in craving during exposure to in vivo smoking cues, reflecting greater increases in craving in the attend group, although these effects were observed in males only. Conclusions These data are the first to show alterations in attentional bias for smoking‐related stimuli following a modified visual probe training procedure. Furthermore, post‐training group differences in subjective craving suggest potential clinical utility of training procedures, although these effects may operate only in males. Future research should investigate whether multiple training sessions enhance post‐training reductions in craving and cue reactivity, and the longer‐term persistence of training effects.     

Visual cue-specific craving is diminished in stressed smokers

Background: Craving among smokers is increased by stress and exposure to smoking-related visual cues. However, few experimental studies have tested both elicitors concurrently and considered how exposures may interact to influence craving. Objective: The current study examined craving in response to stress and visual cue exposure, separately and in succession, in order to better understand the relationship between craving elicitation and the elicitor. Method: Thirty-nine smokers (21 males) who forwent smoking for 30 minutes were randomized to complete a stress task and a visual cue task in counterbalanced orders (creating the experimental groups); for the cue task, counterbalanced blocks of neutral, motivational control, and smoking images were presented. Self-reported craving was assessed after each block of visual stimuli and stress task, and after a recovery period following each task. Results: As expected, the stress and smoking images generated greater craving than neutral or motivational control images (p < .001). Interactions indicated craving in those who completed the stress task first differed from those who completed the visual cues task first (p < .05), such that stress task craving was greater than all image type craving (all p’s < .05) only if the visual cue task was completed first. Conversely, craving was stable across image types when the stress task was completed first. Conclusions: Findings indicate when smokers are stressed, visual cues have little additive effect on craving, and different types of visual cues elicit comparable craving. These findings may imply that once stressed, smokers will crave cigarettes comparably notwithstanding whether they are exposed to smoking image cues.     

The impact of cigarette deprivation and cigarette availability on cue–reactivity in smokers

Aims This experiment was conducted to determine the impact of cigarette deprivation and cigarette availability on reactivity measures to cigarette cues. Participants Smokers were recruited who were 18 years of age or older, not attempting to quit or cut down on their smoking, smoked at least 20 cigarettes daily, had been smoking regularly for past year and had an expired carbon monoxide level of at least 10 parts per million. Design Smokers were assigned randomly to abstain from smoking for 24 hours (n = 51) or continue smoking their regular amount (n = 50). Twenty‐four hours later, they were exposed to trials of either a lit cigarette or a glass of water with a 0, 50 or 100% probability of being able to sample the cue on each trial. Craving, mood, heart rate, skin conductance, puff topography and latency to access door to sample the cue were measured. Findings Both exposure to cigarette cues and increasing availability of those cues produced higher levels of craving to smoke. Deprivation produced a generalized increase in craving. There was no consistent evidence, however, that even under conditions of high cigarette availability, deprived smokers were sensitized selectively to presentations of cigarette cues. Conclusions The data suggest that, even under conditions of immediate cigarette availability, deprivation and cue presentations have independent, additive effects on self‐reported craving levels in smokers.     

Marijuana Craving Questionnaire: development and initial validation of a self-report instrument

Aims . To develop and validate a multi-dimensional questionnaire on marijuana craving. Design and measurements . Current marijuana smokers ( n = 217) not seeking treatment completed a 47-item Marijuana Craving Questionnaire (MCQ) and forms assessing demographics, drug use history, marijuana quit attempts and current mood. Findings . Exploratory and confirmatory factor analyses indicated that a four-factor solution best described the item structure. Factor subscales derived from the 17 items with significant loadings had respectable internal consistencies and were stable across settings and subgroups. The subscales exhibited low to moderate, positive intercorrelations and were significantly correlated with marijuana use history and a wide range of single-item measures of craving. Conclusions . Findings suggested that four specific constructs characterize craving for marijuana: (1) compulsivity, an inability to control marijuana use; (2) emotionality, use of marijuana in anticipation of relief from withdrawal or negative mood; (3) expectancy, anticipation of positive outcomes from smoking marijuana; and (4) purposefulness, intention and planning to use marijuana for positive outcomes. These data indicate that the MCQ is a valid and reliable instrument for assessing marijuana craving in individuals not seeking drug abuse treatment and that marijuana craving can be measured in the absence of withdrawal.     

Depressive symptoms in the trajectory of craving during smoking cessation treatment: A latent growth curve model

Background: Depressive symptoms and craving are related to smoking maintenance; however, little is known about the association between trajectories of depressive symptoms and smoking craving after quitting. Objectives: We examined if depressive symptom change relates to change in craving following smoking cessation treatment. Methods: Participants were 362 (64.1% female; 35.9% male) adult treatment seeking smokers who quit smoking after treatment. Depressive symptoms and craving trajectories were evaluated during smoking cessation treatment until 6 months follow-up. A latent growth curve model was used to study the correlation between trajectories. Results: Depressive symptoms and smoking craving reduced significantly after quitting. Change in depressive symptoms was significantly related to change in craving symptoms over time. Conclusions: Quitting smoking was related to a reduction in depressive symptoms and craving. Clinically, the reduction of depressive symptoms is associated with reduce craving. The data suggest depression plays an important role in craving change following treatment.     

An overview of alcohol and tobacco/nicotine interactions in the human laboratory

ABSTRACT

Background: Alcohol use disorders and tobacco use contribute significant risk to the global burden of disease, and each are major public health concerns. Together, alcohol and tobacco use are highly comorbid and have multiplicative health risks when used concurrently, underscoring the importance of examining alcohol-tobacco interactions in the human laboratory. Objective: The aims of this review were to summarize the state of research examining alcohol-tobacco interactions in the human laboratory. Methods: We reviewed human laboratory evidence for alcohol and tobacco/nicotine interactions, including 1) craving in drinkers and smokers exposed to smoking or drinking cues, 2) fixed-dosing of alcohol or nicotine in smokers and drinkers, and 3) smoking and alcohol influences on self-administration behaviors. The interactive effects of tobacco/nicotine with other drugs of abuse are also briefly discussed. Results: Overall, results identified that alcohol and tobacco have reciprocal influences on potentiating craving, subjective responses to fixed-dose alcohol or nicotine administration, and self-administration. The literature identified that alcohol increases craving to smoke, decreases time to initiate smoking, and increases smoking self-administration. Similarly, tobacco and nicotine increase alcohol craving, decrease subjective effects of alcohol, and increase alcohol consumption. Conclusion: Future studies should continue to focus on alcohol and tobacco/nicotine interactions in individuals with a wide scope of drinking and smoking histories, different states of alcohol and nicotine deprivation, and influences of either drug on craving, subjective responses, and consumption over the course of the blood alcohol curve. This work could have important implications for the impact of alcohol-tobacco interactions on guiding clinical practice, as well as in the changing landscape of addiction.     

Resisting the Urge to Smoke and Craving during a Smoking Quit Attempt on Varenicline: Results from a Pilot FMRI Study

Background: Varenicline has been shown to reduce cigarette craving during a quit attempt. Objectives: Use BOLD fMRI to explore differences in smoking cue reactivity at baseline and after five weeks of varenicline smoking cessation treatment. Methods: Treatment-seeking nicotine-dependent adult smokers underwent BOLD fMRI scans with block presentation of visual smoking, neutral, and rest cues under two conditions: craving or resisting the urge to smoke at baseline and following 5 weeks of standard varenicline therapy. Data were analyzed using FMRI Expert Analysis Tool, version 5.98 of Functional Magnetic Imaging of the Brain Software Library focused on the smoking vs. neutral cue contrast at the individual and group level, Z>2.3 with cluster threshold p=0.05. Results: Twenty-one participants were scanned at baseline and 16 completed the study; 10 were abstinent at the 2^nd session, confirmed with urinary cotinine. In the Crave Condition no significant differences were found between the abstinent and non-abstinent groups at either time point. During the baseline Resist Condition, the abstinent group compared to the non-abstinent group demonstrated activation in a distributed network involved in alertness, learning and memory. Additionally, within the abstinent group, increased activation of the superior frontal gyrus was found at baseline compared to week 5. Conclusion: Successful smoking cessation with varenicline is associated with increased activation, prior to a quit attempt, in brain areas related to attentiveness and memory while resisting the urge to smoke Scientific Significance: Varenicline may exert effects by both reducing craving and enhancing resistance to smoking urges during cue-elicited craving.     

Influence of smoking cues in movies on craving among smokers

Aims   Research has shown that smoking-related cues are important triggers for craving. The objective of the present study was to test whether smoking cues in movies also function as triggers to evoke craving. To accomplish this, we conducted a pilot study in which we examined smokers' reactivity to smoking cues from a particular movie in a common cue–reactivity paradigm using pictures. In the main study, we tested whether smokers who are confronted with smoking characters in a movie segment have a greater desire to smoke than smokers confronted with non-smoking characters.
Design   Using an experimental design, participants were assigned randomly to one of two movie conditions (smoking versus non-smoking characters).
Setting   In a laboratory, that reflected a naturalistic setting, participants watched a 41-minute movie segment.
Participants   A total of 65 young adults who smoked on a daily basis participated in the experiment.
Measurements   Craving was assessed before and after watching the movie.
Findings   The pilot study revealed that pictures of smoking characters had strong effects on craving. However, when smokers actually watched a movie segment, no differences in craving were found between those who watched smoking characters and those who watched non-smoking characters. This finding was not affected by baseline craving, the time of the last cigarette smoked and daily smoking habits.
Conclusions   No effect of smoking cues in movies on craving was found, in contrast with research supporting the cue-craving link. Thus, if replicated, this might indicate that smoking cues in such contexts do not affect smokers' desire to smoke as expected.     

Life expectancy following a cardiovascular event in individuals with and without type 2 diabetes: A UK multi-ethnic population-based observational study

Background and aimsWe aimed to evaluate the life expectancy following the first cardiovascular disease (CVD) event by type 2 diabetes (T2D) status and ethnicity.Methods and resultsWe used the Clinical Practice Research Datalink database in England (UK), linked to the Hospital Episode Statistics information, to identify individuals with and without T2D who survived a first CVD event between 1st Jan 2007 and 31st Dec 2017; subsequent death events were extracted from the Office for National Statistics database. Ethnicity was categorised as White, South Asian (SA), Black, or other. Flexible parametric survival models were used to estimate survival and predict life expectancy. 59,939 individuals with first CVD event were included: 7596 (12.7%) with T2D (60.9% men; mean age at event: 69.7 years [63.2 years in SA, 65.9 in Black, 70.2 in White]) and 52,343 without T2D (56.7% men; 65.9 years [54.7 in Black, 58.2 in SA, 66.3 in White]). Accounting for potential confounders (sex, deprivation, lipid-lowering medication, current smoking, and pre-existing hypertension), comparing individuals with vs without T2D the mortality rate was 53% higher in White (hazard ratio [HR]: 1.53 [95% CI: 1.44, 1.62]), corresponding to a potential loss of 3.87 (3.30, 4.44) life years at the age of 50 years in individuals with T2D. No evidence of a difference in life expectancy was observed in individuals of SA (HR: 0.82 [0.52, 1.29]; −1.36 [-4.58, 1.86] life years), Black (HR: 1.26 [0.59, 2.70]; 1.21 [-2.99, 5.41] life years); and other (HR: 1.64 [0.80, 3.39]; 3.89 [-2.28, 9.99] life years) ethnic group.ConclusionFollowing a CVD event, T2D is associated with a different prognosis and life years lost among ethnic groups.     

A Pilot Trial Examining African American and White Responses to Algorithm-Guided Smoking Cessation Medication Selection in Persons Living with HIV

Algorithm-based treatments (AT) may be an effective clinical tool to aid HIV clinicians in prescribing pharmacotherapy to increase smoking cessation among people living with HIV (PLWH). Initial results from AT indicated significant increases in abstinence self-efficacy and medication utilization and declines in cigarettes smoked per day across time. Given historical racial disparities, it is unclear if both African Americans and White smokers would benefit equally from this type of intervention. Thus, the aim of this study was to examine racial differences in response to AT guided smoking cessation for African American and White smokers living with HIV. One hundred PLWH smokers (n = 100) were randomized to receive either AT guided smoking cessation or Treatment as Usual (TAU) which consisted of instructing participants to talk to a provider about smoking cessation assistance when ready to make a quit attempt. Participants were African American (75%) and White (25%) and majority men (71%) who had never been married (56%). African Americans smoked fewer cigarettes and were more likely to smoke mentholated cigarettes compared to White smokers at baseline. African Americans increased their use of other tobacco products (cigars/cigarillos) over time relative to White smokers. A significant interaction between race and quit goal was observed, with White smokers who reported complete abstinence as their goal having higher quit rates, while African Americans who reported a goal other than complete abstinence demonstrating higher quit rates. The increased use of cigars/cigarillos during quit attempts as well as having a goal other than complete abstinence should be considered when applying algorithm based interventions for PLWH African American smokers.     

Does menthol attenuate the effect of bupropion among African American smokers?

Background African Americans have higher tobacco‐related morbidity and mortality and are more likely to smoke menthol cigarettes than their white counterparts. This study examined differences between African American menthol and non‐menthol smokers in smoking characteristics and cessation. Methods The study sample consisted of 600 African American smokers enrolled in a clinical trial that assessed the efficacy of sustained‐release bupropion for smoking cessation. Menthol (n = 471) and non‐menthol (n = 129) smokers were compared on smoking‐related characteristics and abstinence rates at 6 weeks and 6 months. Results Menthol smokers were younger (41.2 versus 52.9 years), more likely to be female (73.7% versus 56.6%) and more likely to smoke their first cigarette within 30 minutes of waking up (81.7% versus 69.8%) compared to non‐menthol smokers (all P < 0.01). Cigarette taste (50% versus 40%, P = 0.054) was rated non‐significantly higher by menthol smokers. Seven‐day point‐prevalence abstinence from smoking at 6 weeks were 28% and 42% (P = 0.006) and at 6 months were 21% and 27% (P = 0.21) for menthol and non‐menthol smokers, respectively. At 6 weeks follow‐up, stepwise logistic regression revealed that among those younger than 50 years, non‐menthol smokers were more likely to quit smoking (odds ratio = 2.0; 95% CI = 1.03–3.95) as were those who received bupropion (odds ratio = 2.12; 95% CI = 1.32–3.39). Conclusion African American menthol smokers had lower smoking cessation rates after 6 weeks of treatment with bupropion‐SR, thereby putting menthol smokers at greater risk from the health effects of smoking. Lower overall cessation rates among African Americans menthol smokers may partially explain ethnic differences in smoking‐related disease risks.     

Comparative efficacy of rapid-release nicotine gum versus nicotine polacrilex gum in relieving smoking cue-provoked craving

AIMS: Most relapse episodes occur when smokers are confronted with craving provoked by situational cues. Current nicotine gum can help relieve cue-provoked cravings, but faster effects may result in more rapid relief. We tested a prototype formulation of a new rapid-release nicotine gum (RRNG) that provides more rapid release and absorption of nicotine, for its ability to provide faster and better craving relief compared to current nicotine polacrilex gum (NPG). DESIGN: Random assignment to RRNG or NPG, used during a smoking cue provocation procedure. Participants and setting A total of 319 smokers were exposed to a smoking cue in the laboratory by being asked to light but not smoke a cigarette of their preferred brand. Subjects then chewed a piece of 2 mg RRNG (n = 159) or 2 mg NPG (n = 160) according to randomized assignment. MEASUREMENTS: Craving assessments were completed at regular intervals before and after cue exposure (baseline, pre-cue, and 3, 6, 9, 12, 15, 18, 21, 25, 30 and 35 minutes after the cue). FINDINGS: Smokers chewing RRNG showed significantly lower craving than NPG subjects starting with the first assessment at 3 minutes (P < 0.025). Repeated-measures ANOVA revealed a significant treatment x time interaction (P < 0.05)-craving scores dropped more rapidly in RRNG subjects compared to NPG subjects. Survival analyses also indicated superiority of RRNG in achieving more rapid self-reported meaningful relief (P < 0.05) and complete relief (P < 0.05) of craving. CONCLUSIONS: Rapid-release nicotine gum reduced cue-provoked craving more rapidly compared to NPG, and thus merits further study in cessation efficacy trials.     

Divergent trends in lifetime drinking and smoking between Black and White Americans diagnosed with chronic pancreatitis

Background/objectivesBlack Americans are at increased risk of chronic pancreatitis (CP) compared to their White counterparts. We aimed to describe the race-specific smoking history and lifetime drinking in patients diagnosed with CP.MethodsWe analyzed data on 334 Black and White CP participants of the North American Pancreatitis Study 2 Continuation and Validation Study and Ancillary Study. Lifetime drinking history and lifetime smoking history were collected through in-person interviews. Intensity, frequency, duration and current status of drinking and smoking were compared between Black and White CP participants, stratified by physician-defined alcohol etiology. In addition, drinking levels at each successive decades in life (20s, 30s, 40s) were compared by race and graphically portrayed as heat diagrams.ResultsAmong patients with alcoholic CP, current smoking levels were not different by race (67–70%), but a smaller proportion of Black patients reported having smoked 1 or more packs per day in the past (32%) as compared to White patients (58%, p < 0.0001). Black patients were more likely to report current consumption of alcohol (31%), as opposed to White patients (17%, p = 0.016). Black patients also reported more intense drinking at age 35 and 45 years as compared to White patients, while age at CP onset were similar between the two groups.ConclusionWe found more intense drinking but less intense smoking history in Black CP patients as compared to White CP patients. Effective alcohol abstinence and smoking cessation program with sustained impact are needed in CP patients.     

Pre-cessation depressive mood predicts failure to quit smoking: the role of coping and personality traits

AIMS: To examine whether mood, personality and coping predict smoking cessation and whether the associations of personality and coping are mediated through depressed mood. SETTING: Multicenter (n = 8) smoking cessation trial. PARTICIPANTS: A total of 600 smokers (> or = 15 cigarettes/day) without current depression who participated in a smoking cessation study. MEASUREMENTS: The outcome was continuous abstinence during the last 4 weeks of the 3-month trial: depressed mood was measured by the Beck Depression Inventory (BDI), personality by the Revised NEO Personality Inventory (NEO-PI-R) and coping by the Revised Ways of Coping Checklist (RWCC). FINDINGS: A total of 14.7% (88/600) were abstainers. Controlling for potential confounders, baseline BDI independently predicted smoking cessation. Smokers with BDI > or = 10 were less likely to quit than those with BDI < 10 (odds ratio: 6.39, 95% CI: 1.44-28.3, P = 0.01). Compared to BDI < 10 smokers, BDI > or = 10 smokers had significantly higher scores for neuroticism and lower scores for extraversion and conscientiousness (NEO-PI-R). On the RWCC, BDI > or = 10 smokers scored higher for blame self, wishful thinking and problem avoidance and they scored lower on problem focus than smokers with BDI < 10. A mediational analysis showed that neither personality traits nor coping skills predicted directly smoking cessation. However, low level of problem focusing and social support seeking predicted a negative outcome via depressed mood. CONCLUSION: A BDI score > or = 10, even in smokers who do not meet a current diagnosis of major depression, directly predicts inability to quit. This suggests the utility of assessing depression symptoms in routine smoking cessation care.     

Attentional shifts to smoking cues in smokers

Aims Many theories of addiction assume that responses to drug cues maintain drug use and precipitate relapse. There is evidence that measures derived from experimental cognitive psychology yield important information about cue reactivity. We used a pictorial version of the visual probe task to evaluate: (i) whether minimally deprived smokers attend differentially to smoking cues (attentional bias); (ii) whether this bias is related to self‐reported craving and dependence; and (iii) whether it predicted outcome in a subsequent cessation attempt. Design Participants took part in a structured smoking cessation program. Each participant completed the visual probe task roughly 2 weeks before quitting while non‐deprived. Setting A research smoking cessation clinic. Participants 141 heavy smokers seeking treatment for smoking cessation. Measurements The computerized attentional bias measure and self‐reported urge were taken in a laboratory session. Participants also monitored their smoking and craving on electronic diaries both when smoking ad libitum and for up to 6 weeks post‐cessation. Findings Participants were faster and more accurate in responding to a visual probe that replaced a smoking picture than to a neutral picture, indicating that they showed attentional bias towards the smoking cues. Attentional bias on the first half of the task correlated with pre‐task craving, indicating that the bias may tap motivational processes, but it did not predict outcome in smoking cessation. Conclusions The visual probe task can add useful information about attentional responses to drug cues. Further work is required to uncover the theoretical significance and utility of this measure.     

Marijuana withdrawal and craving: influence of the cannabinoid receptor 1 (CNR1) and fatty acid amide hydrolase (FAAH) genes

Aim To examine whether withdrawal after abstinence and cue‐elicited craving were associated with polymorphisms within two genes involved in regulating the endocannabinoid system, cannabinoid receptor 1 (CNR1) and fatty acid amide hydrolase (FAAH). Two single nucleotide polymorphisms (SNPs) in the CNR1 (rs2023239) and FAAH (rs324420) genes, associated previously with substance abuse and functional changes in cannabinoid regulation, were examined in a sample of daily marijuana smokers. Participants Participants were 105 students at the University of Colorado, Boulder between the ages of 18 and 25 years who reported smoking marijuana daily. Measurements Participants were assessed once at baseline and again after 5 days of abstinence, during which they were exposed to a cue‐elicited craving paradigm. Outcome measures were withdrawal and craving collected using self‐reported questionnaires. In addition, urine samples were collected at baseline and on day 5 for the purposes of 11‐nor‐9‐carboxy‐Δ9‐tetrahydrocannabinol (THC–COOH) metabolite analysis. Findings Between the two sessions, THC–COOH metabolite levels decreased significantly, while measures of withdrawal and craving increased significantly. The CNR1 SNP displayed a significant abstinence × genotype interaction on withdrawal, as well as a main effect on overall levels of craving, while the FAAH SNP displayed a significant abstinence × genotype interaction on craving. Conclusions These genetic findings may have both etiological and treatment implications. However, longitudinal studies will be needed to clarify whether these genetic variations influence the trajectory of marijuana use/dependence. The identification of underlying genetic differences in phenotypes such as craving and withdrawal may aid genetically targeted approaches to the treatment of cannabis dependence.     

The urge to smoke depends on the expectation of smoking

Aims An earlier study ( Dols et al. 2000 ) suggested that cue‐induced urge to smoke depends on the expectation of smoking. The present study tried to replicate the findings under stringently controlled conditions. Design A 2 (context) × 2 (cues) × 6 (trial) within‐subject design. Each smoker entered two different contexts; one context predicted the future occurrence of smoking (i.e. one puff of a cigarette) and one context predicted the non‐occurrence of smoking. In each context smokers were exposed to smoking cues (i.e. cigarettes and lighter) or not. Setting Laboratory at Maastricht University. Participants Thirty‐two daily smokers, smoking at least five cigarettes a day for at least 2 years. Measurements. Participants reported their urge to smoke in each context in the presence and absence of smoking cues using a computerized visual analogue scale (VAS). Findings The results revealed that the urge to smoke was higher in a context in which smoking was expected relative to a context in which it was not expected. As in the previous study the urge‐inducing effect of smoking cues was larger in the smoking context than in the non‐smoking context. Moreover, smoking cues did not have a significant effect in the non‐smoking context. Conclusions It was shown that smoking cues elicit craving due mainly to a generated expectation of the occurrence of smoking and less due to salience or long history of associative learning. Theoretical and practical implications of the results are discussed.