Does completing a craving questionnaire promote increased smoking craving? An experimental investigation.

The authors evaluated whether completing a multi-item assessment of smoking craving (the Questionnaire of Smoking Urges [QSU]) promoted increases in smoking craving. A sample of 39 regular smokers was randomly assigned to 1 of 3 manipulations (each of 3 min duration): (a) complete the QSU-Brief (10 items), (b) complete a noncraving questionnaire that was structurally identical to the QSU-Brief (scale-based control), and (c) a time-based control. Participants responded to an oral question assessing their degree of craving immediately before and after the manipulations. Results indicated that the QSU did not promote increases in craving compared to the 2 control conditions. Despite continuing debate over the most appropriate self-report measure of craving, investigators who use the QSU-Brief can be reasonably sure that the scores that result are not biased due to reactivity effects.

Promoting smoking cessation in the rehabilitation setting.

Cigarette smoking is a known risk factor in patients with ischemic and hemorrhagic stroke. Smoking also increases the risk of cardiovascular disease, chronic bronchitis, emphysema, peptic ulcers, and cancer of several organs among middle-aged individuals and the elderly. In the elderly, smoking has also been associated with a general decline in physical functioning as a result of the increased incidence of chronic illnesses. The prevalence of smoking among community-dwelling adults aged 65 to 74 yr has been estimated to be 18% for men and 15% for women. More than 30% of Americans who are hospitalized each year are smokers. Although there are no published studies that have established the prevalence of smoking in a rehabilitation population, these data and our own clinical experience suggest that smoking continues to be a significant health problem for many persons who enter the inpatient rehabilitation setting. Because most hospitals have adopted a smoke-free policy, hospitalization itself may initiate a period of nonsmoking in patients who were smokers at the time of their admission. In addition, some smokers choose to quit smoking after stroke or other medical crisis caused by the health risks associated with cigarette smoking. However, research has also revealed a rather low-smoking cessation rate (30%) among smokers who have had a transient ischemic attack despite the health benefits associated with smoking cessation. Given the significant health risks associated with cigarette smoking, particularly in the elderly and those with cerebrovascular compromise, the effects of smoking on the patient's health should be discussed with the patient during inpatient rehabilitation. Unfortunately, given the current healthcare demands of reducing lengths of hospitalization and the focus on functional outcomes, health promotion issues, such as smoking cessation, nutrition, exercise, may not receive the attention that they deserve. Despite these constraints, we believe that the inpatient rehabilitation setting provides an opportunity for a "teachable moment" to introduce the idea of smoking cessation to the active smoker or to encourage continued smoking cessation and relapse prevention to those patients who have not smoked since their admission to the acute care hospital. If instituted in an effective manner, we believe that there could be significant healthcare benefits in establishing a formal smoking cessation or relapse prevention program in the rehabilitation setting.

Cognitive avoidance as a method of coping with a provocative smoking cue: the moderating effect of nicotine dependence.

Both nicotine dependence and coping are important determinants of smoking cessation, yet little is understood about mechanisms that link the two. This laboratory study investigated how nicotine dependence moderates execution of an avoidance coping strategy. High and low dependent smokers were exposed to a provocative smoking cue (in vivo) under two instructional sets: cognitive avoidance coping and no coping. Contrary to hypotheses, high dependent smokers reported greater increases in perceived self-efficacy to not smoke and also demonstrated greater facility in processing coping/nonsmoking-related information on a reaction time task, compared with low dependent smokers. These counterintuitive findings are discussed in terms of how nicotine dependence may affect the cognitive process of coping.

Individual differences in responses to the first cigarette following overnight abstinence in regular smokers.

We utilized cluster analysis to identify individual differences in response to the initial effects of smoking following overnight abstinence among 183 regular smokers. Participants smoked three cigarettes (1 mg nicotine, spaced 30 min apart) in standardized fashion and completed questionnaires about their subjective responses to each cigarette. Heart rate was monitored throughout the procedure. Participants were grouped into two clusters based on their reported subjective effects and heart rate changes to the first cigarette. Clusters differed in terms of greater increases in heart rate, reports of dizziness, sweating, unpleasantness, nausea, and buzzing sensations in one group compared to the other group. The smokers showing increased responses developed greater acute tolerance to the effects of smoking subsequent cigarettes on subjective negative effects and heart rate, and experienced greater negative affect after quitting. These results are partially consistent with a nicotine sensitivity interpretation or a tolerance model of the effects of initial smoking.

Symptoms of depression and survival experience among three samples of smokers trying to quit.

Symptoms of depression have been associated with increased smoking prevalence and failure to quit smoking in several cross-sectional and population-based studies. Few studies, however, have prospectively examined the ability of current symptoms of depression to predict failure to quit smoking in treatment-motivated smokers. Pretreatment depressed mood was assessed by 3 different methods in 3 separate samples, 2 of which comprised smokers receiving combined pharmacological and behavioral treatments and a 3rd in which smokers received self-help materials only. In all studies, time in days from quit day until the 1st cigarette was ascertained to document survival. Survival analyses showed that in all 3 studies survival time was significantly and negatively related to measures of even very low levels of pretreatment depressed mood. Results were replicated across 3 independent samples and were robust and uniformly clear, indicating that low levels of depressive symptoms assessed at baseline predict time to 1st cigarette smoked after attempted quitting.

A content analysis of smoking craving.

The purpose of this study was to conduct a content analysis of smoking craving in order to investigate more precisely the subjective nature of the construct with the goal of informing assessment. Thirty-two smokers interested in cessation treatment provided free response written descriptions of the level of craving they normally experience. These responses were analyzed for subjective content along five theoretical domains: physiological, affective, cognitive, behavioral, and synonyms (of craving). Although there were no differences in the relative proportion of broad content terms smokers used to describe their craving (e.g., cognitive versus affective), this analysis revealed considerable diversity in the specific terms smokers used. Some smokers described their craving in purely physiological terms whereas others used primarily cognitive terms, and still others used affective terms. To assume that smoking craving is qualitatively similar across persons, then, may mask important variations that define the individual experience of craving.

Effect of different cue stimulus delivery channels on craving reactivity: comparing in vivo and video cues in regular cigarette smokers.

Exposure to smoking cues reliably produces increases in craving compared to exposure to appropriately matched neutral cues. While different types of stimuli have been used as cue materials in such studies, the channel through which cues are delivered is not often varied in a systematic fashion in smoking research. This study compared the effect of exposure to active in vivo cues compared to two cues, matched for content and time, delivered via videotape on self-reported smoking craving. Results revealed that active in vivo cues produced the highest Craving ratings. followed next by active video cues, and last by neutral video cues. These results suggest that craving is sensitive to stimulus delivery channel and that video presentation of smoking cues is a viable manipulation option in cue reactivity studies.

Human immunodeficiency virus infection, AIDS, and smoking cessation: the time is now.

Treatments for persons who are infected with human immunodeficiency virus (HIV) or who have developed AIDS have advanced to the point where death is no longer the inevitable outcome of diagnosis. Combination antiretroviral therapy has made HIV infection less of a terminal condition and more of a medically manageable chronic disease. Thus, efforts to improve the health status and quality of life of HIV-infected persons have become one of the highest treatment priorities for the next decade. Cigarette smoking is highly prevalent among HIV-infected persons, and quitting smoking would greatly improve the health status of these individuals. However, to date, no studies have evaluated the efficacy of a smoking-cessation intervention specifically tailored to this population. This article reviews the evidence and rationale for advancing smoking-cessation treatments specifically tailored to the needs of HIV-infected persons and provides recommendations for future treatment studies.

The measurement of drug craving.

This paper reviews theoretical and methodological issues in the measurement of drug craving, with an emphasis on self-report assessment. Despite the important role that craving plays in many research and clinical settings, the way in which the construct is conceptualized and measured rarely receives sufficient attention. Issues pertinent to conceptualizing craving are identified. Because there is no single perfect measure of craving, it is essential that researchers understand the limitations of each measure. Measurement performance concerns that affect the validity of different measures are reviewed. Non-verbal assessment methods are also reviewed. Research factors that may help determine the optimal measures for a given study are highlighted. It is concluded that advances in assessment will proceed only when combined with additional research and a better theoretical understanding of craving.

Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth.

Youth smoking has risen dramatically during the last 5 years, leading one to the conclusion that prevention interventions have not been particularly effective. This paper provides an examination of features that define adult nicotine dependence and argues that these features need to be considered in any studied examination of youth etiology and development to nicotine dependence. We review the historical context for the concept of nicotine dependence, features that define the concept and current models of substance dependence more generally. Recommendations for future research are provided.

Smoking withdrawal dynamics in unaided quitters.

Considerable research shows that withdrawal severity is inconsistently related to smoking cessation outcomes. This may result from measurement problems or failure to scrutinize important dimensions of the withdrawal experience. Two recent studies demonstrated that withdrawal elevation and variations in the time course of withdrawal were related to relapse in smokers treated with the nicotine patch (T. M. Piasecki, M. C. Fiore, & T. B. Baker, 1998). This article reports a conceptual replication and extension of those findings in unaided quitters. Evidence for temporal heterogeneity was found across different types of withdrawal symptoms. Patterns or slopes of affect and urge reports over time predicted smoking status at follow-up, as did mean elevation in withdrawal symptoms. These results suggest that affect and urge withdrawal symptoms make independent contributions to relapse and that relapse is related to both symptom severity and trajectory.

Cue exposure treatment for smoking relapse prevention: a controlled clinical trial.

AIMS: In an additive design, test the efficacy of cue exposure treatment for smoking relapse prevention as an adjunct to current standard cognitive behavioral and pharmacological treatments. DESIGN: Randomized, controlled clinical trial. SETTING: Outpatient behavioral medicine clinic. PARTICIPANTS: One hundred and twenty-nine cigarette smokers recruited through newspaper advertisements. INTERVENTION: After receiving an initial counseling session for cessation and setting a quit day, 129 smokers were randomly assigned to one of four relapse prevention treatment conditions: (1) brief cognitive behavioral; (2) cognitive behavioral and nicorette gum; (3) cognitive behavioral and cue exposure; and (4) cognitive behavioral and cue exposure with nicorette gum. All smokers met individually with their counselor for six RP sessions. MEASURES: Seven-day, point-prevalence abstinence rates (CO verified) taken at 1, 3, 6 and 12-months post-treatment and time to first slip. FINDINGS: All manipulation checks and process measures suggested that the treatments were delivered as intended. There were no significant differences between conditions in point-prevalence abstinence rates or in time to first slip. CONCLUSIONS: These results call into question the utility of cue exposure treatment for smoking relapse prevention.

Do processes of change predict smoking stage movements? A prospective analysis of the transtheoretical model.

The transtheoretical model (TTM) posits that processes of change and the pros and cons of smoking predict progressive movement through the stages of change. This study provides both a cross-sectional replication and a prospective test of this hypothesis. As part of a larger study of worksite cancer prevention (the Working Well Trial), employees of 26 manufacturing worksites completed a baseline and 2 annual follow-up surveys. Of the 63% of employees completing baseline surveys, 27.7% were smokers (N = 1,535), and a cohort of these smokers completed the 2-year follow-up. Cross-sectional results replicated previous studies with virtually all the processes of change and the cons of smoking increasing in linear fashion from precontemplation to preparation (all ps < .00001), and the pros of smoking decreasing (p < .01). However, contrary to the hypothesis, the baseline processes of change and the pros and cons of smoking failed to predict progressive stage movements at either the 1- or the 2-year follow-ups. Possible explanations for these findings and concerns about the conceptual internal consistency of the TTM are discussed.

The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking.

Worksites are a key channel for delivery of interventions designed to reduce chronic disease among adult populations. Although some evaluations of worksite physical-activity interventions have been conducted, to date very few randomized trials of worksite health promotion have included the goal of increasing physical-activity levels as part of a comprehensive multiple risk factor approach to worksite health promotion. This article presents the results regarding behavior change found among the cohort of 2055 individuals who completed three health-behavior assessments as part of their worksites' participation in The Working Healthy Project (WHP), a multiple risk factor intervention implemented in 26 manufacturing worksites. In this study, a randomized matched-pair design was used. Fifty-one percent (n = 2,761) of the employees who completed the baseline assessment also completed the interim survey. Eighty-three percent of those who completed the interim assessment also completed the final survey. The WHP intervention targeted smoking, nutrition, and physical activity. At baseline, 38% of the sample reported engaging in regular exercise, and subjects reported consuming an average of 2.7 servings of fruits and vegetables per day, 7.9 grams of fiber per 1000 kilocalories, and 35.4% calories from fat per day; 28% of the sample were smokers. By the time of both the interim (intervention midpoint) and final (end of intervention) assessments, participants in the intervention condition had significantly increased their exercise behavior, compared with the control condition. There was also increased consumption of fruits and vegetables and fiber in the intervention condition by the time of the final assessment, compared with the control condition. No differences by condition were found with regard to percentage of calories from fat consumed or smoking cessation. These results suggest that among a cohort of participants in a worksite health promotion study, there were significant health behavior changes across two risk factors over time. These data suggest that further investigation of multiple risk factor worksite health promotion is warranted, particularly with a focus on ways to increase participation in these programs and to diffuse intervention effects throughout the entire workforce.

History and symptoms of depression among smokers during a self-initiated quit attempt.

History of depression in smokers has been associated with an inability to quit smoking and with an increased likelihood of smoking relapse. This study prospectively tracked nicotine withdrawal symptoms, symptoms of depression, and ability to quit smoking between smokers with and without a probable history of major depression who were trying to quit smoking with minimal assistance. Results indicated that prior to quitting, smokers with a history of depression smoked to reduce negative affect, in response to craving, and in social situations. Additionally, positive history smokers scored higher on the Center for Epidemiological Studies Depression Scale (CES-D) than did smokers without such a history. Following a quit attempt, positive history smokers were somewhat more likely to experience greater symptoms of nicotine withdrawal than negative history smokers. However, among the positive history smokers, depressive symptoms as measured by the CES-D increased significantly 4 weeks after trying to quit, compared to a decline among negative history smokers. Positive and negative history smokers did not significantly differ on ability to quit smoking within the 30-day follow-up period. History of depression appears to be associated with a delayed increase in symptoms of depression following a quit attempt. However, it remains to be demonstrated whether such an increase in depressive symptoms may influence later probability of relapse.

Scripted imagery manipulations and smoking cue reactivity in a clinical sample of self-quitters.

The affectively valenced scripts used by S. Tiffany (1990) suggest that different scripts produce relatively equivalent levels of cue reactivity, although it is unclear if these laboratory findings generalize to clinical samples. In this study, cessation-motivated smokers were tested 7 days before they tried to quit smoking and were exposed to 3 audiotaped scripts that depicted different affectively valenced situations (neutral, positive, or negative). The latter 2 scripts also contained smoking cues. The findings using a clinical sample differed considerably from those using analogue laboratory samples across affective, cognitive, and physiological response measures. Reactivity to these standardized scripts failed to predict treatment outcome through a 30-day follow-up. The use of affectively valenced scripts beyond a laboratory sample is questioned.

Individual differences in cue reactivity among smokers trying to quit: effects of gender and cue type.

Across studies, when presented with a variety of smoking cues, smokers and ex-smokers evidence distinct patterns of self-reported, physiological, and behavioral reactions. However, few studies have compared more than two different kinds of cues within the same experiment. Furthermore, despite the importance of examining the moderating effect of gender on smoking outcomes, few studies have examined gender differences in smoking cue reactivity. We examined the effect of eight distinct cue manipulations on heart rate, mean arterial pressure, smoking urges, and self-efficacy in a sample of 129 participants (50% female) who had recently quit smoking. Cue manipulations included (a) in vivo exposure, (b) an idiographically designed exposure of subjects' most recent relapse, (c) an idiographically designed exposure to subjects' highest risk situation, and (d) affectively valenced standardized scripts depicting situations generally associated with relapse. These manipulations were compared to a standard cognitive stressor (mental arithmetic) and to a resting baseline. Results revealed differences in the degree of reactivity to different manipulations, with in vivo cues producing the greatest changes. Gender differences in reactivity between the type of cues presented were found for mean arterial pressure, with standardized scripts producing greater changes for women. These findings have implications for understanding the reasons for differences in cue reactivity across manipulations and for gender differences in cue reactivity.

Self-concept changes over time in cognitive-behavioral treatment for smoking cessation.

A smoker self-concept and an abstainer self-concept are individual difference variables that have been shown to predict smoking cessation. We examined whether these self-concept constructs changed as a function of participating in a clinic-based smoking cessation program and, specifically, whether these changes occurred differentially between posttreatment smokers and abstainers. Subjects completed the Smoker Self-concept scale and the Abstainer Self-concept scale at three time points: pretreatment, posttreatment, and 3 months' posttreatment. Smoking status was assessed and biochemically verified directly after quit day and 3 months' posttreatment. Results indicated that abstainers' smoker self-concept decreased more precipitously over time compared to smokers'. Abstainers showed consistent increases over time in their abstainer self-concept, and smokers showed increases followed by decreases to pretreatment levels. Clinical implications are discussed.

Individual differences in self-concept among smokers attempting to quit: Validation and predictive utility of measures of the smoker self-concept and abstainer self-concept.

We tested a theoretical model of individual differences in smoking cessation using a social-cognitive conception of the self-concept. We developed and validated measures of the smoker self-concept and the abstainer self-concept. Each scale was shown to have good internal reliability and construct validity and was distinct from other important predictive measures used in smoking research (e.g. Fagerstrom Tolerance Questionnaire, smoking rate, motivation, self-efficacy). Importantly, we demonstrated the predictive validity of the self-concept scales. The interaction of baseline measures of the smoker self-concept and abstainer self-concept predicted smoking status three months after treatment; subjects were most likely to be abstinent if they began treatment with a strong abstainer selfconcept and a weak smoker self-concept. This interaction held over and above baseline smoking rate, Fagerstrom Tolerance scores, and measures of motivation and self-efficacy to quit. The utility of social-cognitive individual difference models and potential patient-treatment matching interventions are discussed.

Cigarette smoking under stress: the role of coping expectancies among smokers in a clinic-based smoking cessation program.

This study examined 2 expectancies to explain smoking under stress: smokers' expectations about their ability to cope with stress while remaining abstinent and their expectations about the stress-ameliorating and coping benefits of smoking under stress. The interaction of the expectancies concurrently predicted smoking urge under stress, which, in turn, predicted subsequent smoking. The interaction of posttreatment expectancies prospectively predicted smoking status 3 months after treatment, although the coping benefits of smoking expectancy effect was reversed. Expectations about coping ability increased and expectations about the coping benefits of smoking decreased as a function of participating in a smoking cessation program. The discrepant concurrent and prospective findings, reasons that coping expectancies are associated with smoking under stress, and treatment implications are discussed.