Using the methods of ecological momentary assessment in substance dependence research--smoking cessation as a case study

Ecological momentary assessment (EMA) is the name applied to any of a range of research methodologies that aim to assess participants in near real time as they go about their regular day-to-day activities. Such methods have particular utility for studying drug use and drug dependence. Using the area of nicotine dependence as a case study, this review highlights how EMA can be used to build upon the findings from more traditional research methods to enhance our understanding of drug use. Particular attention is given to the role that advances in technology have played in the adoption of EMA in drug dependence research.     

Prediction of lapse from associations between smoking and situational antecedents assessed by ecological momentary assessment

Smoking is associated with particular moods and activities, but it is not known whether there are individual differences in these associations and whether these differences are associated with success in smoking cessation. We assessed such associations using ecological momentary assessment: real-world, real-time data, collected by palm-top computer. Two hundred and fourteen smokers participating in a smoking cessation study provided data during ad lib smoking at baseline. Participants recorded moods and activities each time they smoked and, for comparison, at randomly selected non-smoking occasions. Situational associations with smoking were captured by examining the associations between smoking and antecedents considered relevant to lapse risk: negative affect (NA), arousal, socializing with others, the presence of others smoking, and consumption of coffee and alcohol. The associations varied across participants, confirming individual differences in situational smoking associations. Survival analyses revealed that only the NA pattern predicted first lapse. The effect was only seen in EMA assessments of NA smoking, and was not captured by questionnaire measures of negative affect smoking, which did not predict lapse risk. Moreover, the effect was not mediated by nicotine dependence.     

Evaluating the utility of administering a reaction time task in an ecological momentary assessment study

RATIONALE: Cognitive processes underlying drug use have typically been assessed in laboratory settings. More detailed and ecologically valid data may be possible if assessments were conducted in an ecological momentary assessment (EMA) setting. OBJECTIVES: We evaluated the feasibility and utility of administering a reaction time task on a hand-held computer (personal digital assistant, PDA) in an EMA setting. MATERIALS AND METHODS: Twenty-two smokers and 22 non-smokers carried around the PDA for 1 week as they went about their daily lives. They were beeped at random times four times per day (random assessments, RAs). Participants were also instructed to press an "anxiety assessment" (AA) button on the PDA whenever they felt suddenly anxious. At each assessment (RA, AA), participants responded to items assessing subjective, pharmacological, and contextual variables, and subsequently completed a Stroop task (classic-Stroop, emotional-Stroop, or smoking-Stroop task). RESULTS: Participants responded to 81.2% of RAs, completed assessments in an average of 4.44 min, reported no interruptions on the majority of assessments (62.4%), and produced data with adequate reliability. Using generalized estimating equation (GEE) analyses, age was associated with the classic-Stroop effect, state anxiety was associated with the emotional-Stroop effect, and Fagerstrom Test for Nicotine Dependence scores were associated with the smoking-Stroop effect. CONCLUSIONS: The study provided evidence for the feasibility and utility of the approach.     

Pharmacotherapies to enhance smoking cessation during pregnancy

Smoking during pregnancy is a significant public health concern. Maternal smoking increases the risk of spontaneous abortion, low birth weight, premature delivery, sudden infant death syndrome and learning and behavioral problems in the offspring. Unfortunately, the majority of pregnant women do not quit smoking during pregnancy. Although pharmacotherapy may improve smoking cessation rates in pregnancy, very few studies exist that have studied the safety and efficacy of medications to treat pregnant smokers. This article reviews the available safety and efficacy data for the use in pregnancy of the five first-line therapies and two second-line therapies that are recommended for smoking cessation in non-pregnant smokers. Other promising nicotine replacement therapies are also reviewed. Ultimately, the choice whether to use pharmacotherapy for smoking cessation should be made jointly by the pregnant smoker and her health care provider. This article reviews factors that may be considered when prescribing pharmacotherapy to pregnant smokers (i.e. the role of behavioral counseling, identification of appropriate patients, potential advantages and disadvantages of each of the pharmacotherapies, proposed monitoring strategies, dose and duration and goals of treatment). More research regarding the safety and efficacy of pharmacotherapy during pregnancy is needed to define the risk/benefit profile of each medication for use in smoking cessation in pregnant women. [Oncken CA, Kranzler HR. Pharmacotherapies to enhance smoking cessation during pregnancy. Drug Alcohol Rev 2003;22:191 - 202]     

Cannabis use during a voluntary quit attempt: An analysis from ecological momentary assessment

Background

There is little research that has sought to identify factors related to quit success and failure among cannabis users. The current study examined affective, cognitive, and situational factors related to cannabis use among current cannabis users undergoing a voluntary, self-guided quit attempt.

Method

The sample consisted of 30 (33% female) current cannabis users, 84% of whom evinced a current cannabis use disorder. Ecological momentary assessment was used to collect multiple daily ratings of cannabis withdrawal, negative affect, peer cannabis use, reasons for use, and successful coping strategies over two weeks.

Results

Findings from generalized linear models indicated that cannabis withdrawal and positive and negative affect were significantly higher during cannabis use than non-use episodes. Additionally, when negative and positive affect were entered simultaneously, negative affect, but not positive affect, remained significantly related to use. Participants were significantly more likely to use in social situations than when alone. When participants were in social situations, they were significantly more likely to use if others were using. Participants tended to use more behavioral than cognitive strategies to abstain from cannabis. The most common reason for use was to cope with negative affect.

Conclusions

Overall, these novel findings indicate that cannabis withdrawal, affect (especially negative affect), and peer use play important roles in cannabis use among self-quitters.     

Pharmaceutical strategies for smoking cessation during pregnancy

ABSTRACT

Introduction

Tobacco use is the most preventable cause of death worldwide, with over 7 million deaths per year. Smoking during pregnancy causes harm to the mother, fetus, and can result in problems for the infant from childhood into adulthood. Practitioners should ask all expectant mothers about tobacco use. For expectant mothers who smoke or recently quit, practitioners should advice to quit and provide psychosocial interventions. Rates of smoking during pregnancy differ between geographical locations, with estimates of 10.8% in the UK and 7.2% in the US. Practitioners should provide expectant mothers unable to quit smoking with information about the risks and benefits of pharmacotherapy and use a patient-centered approach to determine the use. Although there is no definitive evidence on birth outcomes, nicotine replacement therapy and bupropion are adequate pharmacotherapies to help those unable to quit.     

Effect of smoking cessation and relapse on cardiovascular levels and reactivity

This study was designed to investigate the effect of smoking cessation on heart rate, blood pressure, and finger temperature absolute levels and reactivity to a range of laboratory challenges. The 148 quitters (mean age=43.3 years, mean amount smoked=24.9 cigarettes per day, mean years smoked=25.2) completed three assessments: an average of 4±2.8 days before cessation (Exam 1), an average of 2±1.0 days after cessation (Exam 2), and an average of 20±5.5 days after cessation (Exam 3). A nonsmoking group (n=39) was similarly assessed three times to control for effects related to repeated testing. Comparison of group changes from Exam 1 to Exam 2 indicated that smoking cessation produced a significant decrease in heart rate during rest and during all stressors (mean=–8.9 bpm). Those quitters who remained abstinent or smoked occasionally showed minimal changes in heart rate from Exam 2 to Exam 3, but those quitters who returned to their previous smoking level showed a significant increase in heart rate from Exam 2 to Exam 3. None of the indices of cardiovascular reactivity changed across exams, and neither did absolute levels of blood pressure or finger temperature at rest or during stressors. The possible mechanisms producing a selective heart rate decline after smoking cessation in the absence of pressor or vasodilation effects are discussed.     

Bupropion to aid smoking cessation

Around 1 in 4 adults in the UK smoke cigarettes and about two-thirds say they would like to give them up. However, giving up permanently is difficult, and each year, only about 2% of all smokers manage to do so. [symbol: see text]Bupropion (Zyban-GlaxoWellcome) has recently been licensed "as an aid to smoking cessation in combination with motivational support". The manufacturer claims that there is evidence that the drug is "almost twice as effective as a nicotine patch in achieving smoking abstinence at one year". Here, we assess the efficacy and safety of bupropion in helping people stop smoking.     

Cell phones for ecological momentary assessment with cocaine-addicted homeless patients in treatment

This is the first study to examine whether cell phones could be used to collect ecological momentary assessment (EMA) data with homeless crack cocaine-addicted adults in treatment. The study adapted an EMA method to examine behavior in real time using cell phones and computer-automated telephone interviewing. Participants treated in an intensive outpatient treatment program were given cell phones for a 2-week period to record current states of cocaine craving and using episodes. Results showed cell phone technology could reliably deliver a computerized survey; this homeless population would use a cell phone to report craving and using episodes, and drug use reported via EMA was in agreement with urine toxicology results for 73% of participants. Of 30 participants, 24 (80%) completed the full 2-week protocol. Participants indicated the survey made them more aware of phenomena leading to cravings and use, suggesting the usefulness of EMA as a potential intervention.     

The feasibility of using cellular phones to collect ecological momentary assessment data: application to alcohol consumption

The limitations of paper-and-pencil self-monitoring (PM) are leading to the use of more sophisticated techniques. PM was compared with cellular phone monitoring (CM) to collect ecological momentary assessment data on alcohol use. Twenty social drinkers were randomly assigned to the 2 groups, and their drinking was monitored for 14 days. PM participants recorded data on cards. CM participants carried telephones and responded to an interactive voice response system. The authors found few significant group differences in alcohol use, compliance with the self-monitoring, and satisfaction. However, CM had useful advantages, including instantaneous entry of data into a central database, date and time stamping of data, and easy integration into daily life. Although preliminary, this study suggests that CM is a promising alternative to PM.     

Management of emergent psychiatric symptoms during smoking cessation

ABSTRACT

Background: Tobacco smoking is a major risk factor for cardiovascular disease, respiratory disease and cancer and, for current smokers, smoking cessation is one of the most effective therapeutic interventions for reducing the risk of all-cause morbidity and mortality. However, smoking cessation causes nicotine withdrawal syndrome, a condition with symptoms that overlap those of major depression and anxiety disorders.

Scope: The objective of this review was to examine the evidence that smoking cessation may be associated with new onset of psychiatric illness, particularly in individuals with no history of psychiatric disease, and to provide recommendations for the management of emergent psychiatric symptoms in smokers attempting cessation. Relevant articles were obtained from a MEDLINE search (articles indexed up to, and including, October 2008, with no historical date limit), and citation review of selected primary and review articles.

Findings: There is evidence that smoking cessation can result in new onset of major depressive disorder, even in individuals with no history of depression. It has also been suggested that nicotine may be used as a form of self-medication for depression, and that smoking cessation can reveal a previously undiagnosed condition. There is little evidence of an association between smoking cessation and increased risk for other types of psychiatric illness. The management of emergent psychiatric symptoms in smokers attempting abstinence is discussed.

Conclusion: The overall health benefits of quitting smoking undoubtedly outweigh any potential side-effects associated with nicotine withdrawal. However, a well-managed quit attempt must plan for the emergence of nicotine withdrawal, monitor for symptoms of depression and psychiatric disease, and manage these conditions appropriately should they present.     

Effectiveness of bupropion for smoking cessation during pregnancy

Gestational smoking has been established as a risk to the fetus. However, many pregnant smokers are unable to quit due to the highly addictive nature of nicotine. Nicotine replacement therapy has failed in several studies in pregnant women. In a prospective matched, controlled observational study, of 22 pregnant smokers receiving bupropion, 10 (45%) ceased smoking, as compared to 3 (14%) of 22 controls (P = 0.047). Bupropion appears to be effective for smoking cessation therapy during pregnancy.     

Clinical phenotypes related to smoking cessation

Introduction

The aim of the current study is the identification of clinical phenotypes of patients visiting a specialized smoking cessation center and the determination of smoking cessation rate for each phenotype, 1 year after the initial evaluation.

Methods

Seven hundred eighty-three smokers who visited the outpatient clinic were included in the study. Demographic data, smoking habits, tobacco dependence and comorbidities were recorded. Smoking cessation rates and carbon monoxide levels were determined 1 year after the initial evaluation.

Results

Τhe overall smoking cessation rate 1 year after the initial evaluation was 32.3%. Four distinct phenotypes were identified. The first one included mainly young women with low tobacco dependence and allergic profile. The second and the third ones included mainly men with high tobacco dependence, without comorbidities, treated with varenicline and bupropione SR, respectively. The fourth one included mainly older men with high tobacco dependence and smoking related comorbidities. Smoking cessation rates for each phenotype were 33.8, 39.4, 23.3, and 24.6%, respectively.

Conclusion

Patients visiting a specialized smoking cessation center can be categorized in different phenotypes. Phenotyping may lead to a more personalized approach concerning smoking cessation.     

Nicotine replacement to aid smoking cessation

Cigarette smoking remains the commonest cause of preventable mortality in the UK, accounting for about 120,000 deaths each year among people aged 35 years or more. In all, smoking-related disease costs a typical health authority around 15 million Pounds a year. It is notoriously difficult to stop smoking but success rates are increased if cigarettes are replaced by nicotine given as a medicine. When reviewing nicotine replacement in 1993, we recommended a "combined approach, using nicotine patches plus advice and support". Since then, other forms of nicotine replacement have become available. Here we discuss current evidence on the efficacy and safety of different forms of nicotine replacement and consider the place of such therapy.     

Affective reactivity during smoking cessation of never-quitters as compared with that of abstainers, relapsers, and continuing smokers

Much effort has been devoted to examining the differences in postcessation affective experience between smoking abstainers and relapsers. However, little attention has been given to the affective changes of smokers who, despite their motivation to quit, fail to achieve even a brief period of abstinence. Using affect-modulated startle response and self-report questionnaires, we measured the postcessation affective changes of 115 smokers (60 men, 55 women) who participated in a laboratory investigation of affective reactivity during smoking cessation. Among our participants, 34 were abstainers (16 men, 18 women), 16 were never-quitters (8 men, 8 women), 19 were relapsers (8 men, 11 women), and 46 were controls (28 men, 18 women). We found a significant Stimulus Valence × Session × Group interaction effect on startle responses, which suggested that while abstainers, relapsers, and control exhibited the prototypical affect-modulated startle response across postcessation sessions, never-quitters displayed an atypical response pattern in which emotional pictures no longer modulated the startle response. Never-quitters also reported increasingly higher negative and lower positive affect across postcessation sessions. Using affect-modulated startle response and self-report questionnaires, this study found a significant difference in the affective reactivity between smokers who could and smokers who could not establish an initial abstinence of 24 hours.     

Startle response during smoking and 24 h after withdrawal predicts successful smoking cessation

RATIONALE: The startle response is thought to reflect changes in attentional processes in humans. The startle response shows a number of forms of plasticity, of which prepulse inhibition (PPI) refers to the attenuation of the startle response to a strong sensory stimulus (pulse), when such a pulse is preceded by a stimulus of lower intensity (prepulse). Recent studies have shown that nicotine modulates startle and PPI of the startle reflex in humans and animals. The present study examined individual differences in cognitive benefits obtained from smoking as indexed by startle response and PPI. OBJECTIVES: We investigated, using a within-subjects design, the effects of cigarette smoking via a comparison of baseline and withdrawal measures of startle and PPI in 18 subjects wishing to quit cigarette smoking. The relapse of five of these subjects enabled a between-group comparison of these measures with the successful quitters. METHODS: Startle and PPI were measured on three separate occasions: before quitting, 24 h after quitting and 1 month after quitting. RESULTS: The presence of a high startle response amplitude while subjects were still engaged in their normal smoking patterns (baseline) and the occurrence of a significant drop of startle amplitude in withdrawal relative to baseline factors were found to be predictive of an individual's ability to quit smoking. Changes in PPI were found to reflect these changes in startle amplitude. CONCLUSIONS: The observed response patterns are discussed in terms of individual differences in commitment to quitting and self-dosing to manipulate attentional mechanisms as measured by the acoustic startle response. Furthermore, it is suggested that these specific response profiles may be predictive of the ability to quit smoking.     

Responsiveness to reward following cessation of smoking

Rationale and objectives

It has been suggested that stopping smoking may lead to reduced responsiveness to rewarding stimulation. We assessed such changes in dependent smokers who abstained from smoking continuously for 4 weeks.

Methods

Eight hundred seventy-four consecutive smokers treated at a UK Clinic provided ratings of changes in their perception of rewarding events at 1 and 4 weeks after their target quit date. Measurements included the Enjoyment of Life Questionnaire (EOL) and Mood and Physical Symptoms Scale (a measure of withdrawal discomfort). Self-reports of continuous abstinence were verified by expired air carbon monoxide readings.

Results

In 585 participants who were continuously abstinent for the first week and provided EOL ratings, there was an increase in positive reactions to rewarding events compared to reactions while smoking (t?=?5.9, p?<?0.001). In 192 participants who were continuously abstinent for 4 weeks and provided ratings at both 1 and 4 weeks, there was a further significant increase in positive reactions (F(1,191)?=?18.71, p?<?0.001). More severe withdrawal discomfort was related to decreased enjoyment of rewarding events.

Conclusions

Responsiveness to reward increases within a week of stopping smoking and it increases further after 4 weeks of abstinence. The finding has implications for reassuring smokers worried about post-quitting mood changes.