Danielle E. McCarthy

Addiction motivation reformulated: an affective processing model of negative reinforcement.

This article offers a reformulation of the negative reinforcement model of drug addiction and proposes that the escape and avoidance of negative affect is the prepotent motive for addictive drug use. The authors posit that negative affect is the motivational core of the withdrawal syndrome and argue that, through repeated cycles of drug use and withdrawal, addicted organisms learn to detect interoceptive cues of negative affect preconsciously. Thus, the motivational basis of much drug use is opaque and tends not to reflect cognitive control. When either stressors or abstinence causes negative affect to grow and enter consciousness, increasing negative affect biases information processing in ways that promote renewed drug administration. After explicating their model, the authors address previous critiques of negative reinforcement models in light of their reformulation and review predictions generated by their model.

Time to First Cigarette in the Morning as an Index of Ability to Quit Smoking: Implications for Nicotine Dependence

An inability to maintain abstinence is a key indicator of tobacco dependence. Unfortunately, little evidence exists regarding the ability of the major tobacco dependence measures to predict smoking cessation outcome. This paper used data from four placebo-controlled smoking cessation trials and one international epidemiological study to determine relations between cessation success and the Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index, the Nicotine Dependence Syndrome Scale, and the Wisconsin Inventory of Smoking Dependence Motives. Results showed that much of the predictive validity of the FTND could be attributed to its first item, time to first cigarette in the morning, and this item had greater validity than any other single measure. Thus the time-to-first-cigarette item appears to tap a pattern of heavy, uninterrupted, and automatic smoking and may be a good single-item measure of nicotine dependence.

Assessing Tobacco Dependence: A Guide to Measure Evaluation and Selection

Tobacco dependence is a key construct in tobacco research. This paper describes a construct validation approach to dependence assessment and describes key conceptual and psychometric criteria on which to evaluate putative measures of dependence. Five current dependence scales-the Fagerström Test for Nicotine Dependence; the Diagnostic and Statistical Manual of Mental Disorders (4th ed.); the Cigarette Dependence Scale; the Nicotine Dependence Syndrome Scale; and the Wisconsin Inventory of Smoking Dependence Motives-are examined with respect to these critical dimensions. Recommendations are made regarding the use of each measure.

Life Before and After Quitting Smoking: An Electronic Diary Study

This article describes a multidimensional, multivariate, and multilevel approach to the assessment of nicotine withdrawal. In this prospective study, 70 adult smokers assigned to an active or placebo nicotine patch condition completed multiple daily assessments using an electronic diary. Average and individual growth curves were estimated for affective and nonaffective withdrawal symptoms. All symptoms but hunger increased significantly on the quit day and remained elevated for three weeks. Variability in symptom experiences across individuals increased from pre- to post-quit. Relations between symptom reports (e.g., negative affect or craving) and episodic events (e.g., stressful events or seeing someone smoke) changed from pre-quit to post-quit. Pre-quit increases in negative affect and quit-day increases in craving were inversely related to abstinence three months after the quit day, suggesting that anticipatory and immediate reactions to quitting influence success.

Comparative Effectiveness of 5 Smoking Cessation Pharmacotherapies in Primary Care Clinics

BACKGROUND Randomized efficacy clinical trials conducted in research settings may not accurately reflect the benefits of tobacco dependence treatments when used in real-world clinical settings. Effectiveness trials (eg, in primary care settings) are needed to estimate the benefits of cessation treatments in real-world use. METHODS A total of 1346 primary care patients attending routine appointments were recruited by medical assistants in 12 primary care clinics. Patients were randomly assigned to 5 active pharmacotherapies: 3 monotherapies (nicotine patch, nicotine lozenge, and bupropion hydrochloride sustained release [SR]) and 2 combination therapies (patch + lozenge and bupropion SR + lozenge). Patients were referred to a telephone quit line for cessation counseling. Primary outcomes included 7-day point prevalence abstinence at 1 week, 8 weeks, and 6 months after quitting and number of days to relapse. RESULTS Among 7128 eligible smokers (> or =10 cigarettes per day) attending routine primary care appointments, 1346 (18.9%) were enrolled in the study. Six-month abstinence rates for the 5 active pharmacotherapies were the following: bupropion SR, 16.8%; lozenge, 19.9%; patch, 17.7%; patch + lozenge, 26.9%; and bupropion SR + lozenge, 29.9%. Bupropion SR + lozenge was superior to all of the monotherapies (odds ratio, 0.46-0.56); patch + lozenge was superior to patch and bupropion monotherapies (odds ratio, 0.56 and 0.54, respectively). CONCLUSIONS One in 5 smokers attending a routine primary care appointment was willing to make a serious quit attempt that included evidence-based counseling and medication. In this comparative effectiveness study of 5 tobacco dependence treatments, combination pharmacotherapy significantly increased abstinence compared with monotherapies. Provision of free cessation medications plus quit line counseling arranged in the primary care setting holds promise for assisting large numbers of smokers to quit. Trial Registration clinicaltrials.gov Identifier: NCT00296647.

Assessing dimensions of nicotine dependence: An evaluation of the Nicotine Dependence Syndrome Scale (NDSS) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM)

Considerable research, ranging from survey to clinical to genetic, has utilized traditional measures of tobacco dependence, such as the Fagerstrom Test of Nicotine Dependence (FTND) and the Diagnostic and Statistical Manual (4th ed.) (DSM-IV) criteria, that focus on endpoint definitions of tobacco dependence such as heavy smoking, time to first cigarette in the morning, and smoking despite consequences. In an effort to better understand possible theories and mechanisms underlying tobacco dependence, which could be used to improve treatment and research, two multidimensional measures of tobacco dependence have been developed: the Nicotine Dependence Syndrome Scale (NDSS) and the Wisconsin Inventory of Smoking Dependence Motives (WISDM). This research used data from three randomized smoking cessation trials to examine the internal consistency and validity (convergent, concurrent and predictive) of these scales, relative to each other and the traditional measures. Results reveal that NDSS and WISDM subscales are related to important dependence criteria, but in a heterogeneous fashion. The data suggest that there are important underlying mechanisms or motives that are significantly related to different important outcomes, such as withdrawal and cessation. The FTND was most strongly related to abstinence at 1 week and 6 months post-quit, whereas the WISDM Tolerance subscale was most strongly related to abstinence at the end of treatment. The NDSS Priority subscale was consistently predictive of outcome at all three follow-up time points. There is also evidence that WISDM subscales are related to a biomarker of the rate of nicotine metabolism.

Using mediational models to explore the nature of tobacco motivation and tobacco treatment effects.

Various theories have proposed mechanisms for drug motivation and relapse. For instance, negative reinforcement theories focus on the alleviation of withdrawal. However, other theories and some data cast doubt on the importance of withdrawal as a motivator of addictive drug use. Using data from a randomized double-blind placebo-controlled smoking cessation treatment study (N=608), this research examined the impact of withdrawal on drug motivation and the ability to maintain abstinence. Withdrawal was experimentally manipulated by randomly assigning participants to receive active bupropion versus placebo. Mediation analyses revealed that active bupropion reduced the amount of withdrawal and craving that individuals reported in the 1st week post quit; modest support was also found for smaller declines in positive affect. These effects, in turn, were all positively associated with posttreatment abstinence. These results implicate withdrawal as an important factor in motivating persistent tobacco use.

Psychological mediators of bupropion sustained‐release treatment for smoking cessation

AIM The study aimed to test simultaneously our understanding of the effects of bupropion sustained-release (SR) treatment on putative mediators and our understanding of determinants of post-quit abstinence, including withdrawal distress, cigarette craving, positive affect and subjective reactions to cigarettes smoked during a lapse. The specificity of bupropion SR effects was also tested in exploratory analyses. DESIGN Data from a randomized, placebo-controlled clinical trial of bupropion SR were submitted to mediation analyses. SETTING Center for Tobacco Research and Intervention, Madison, WI, USA. PARTICIPANTS A total of 403 adult, daily smokers without contraindications to bupropion SR use. INTERVENTION Participants were assigned randomly to receive a 9-week course of bupropion SR or placebo pill and to receive eight brief individual counseling sessions or no counseling. MEASUREMENTS Ecological momentary assessment ratings of smoking behavior and putative mediators were collected pre- and post-quit. FINDINGS Results of structural equation and hierarchical linear models did not support the hypothesis that bupropion SR treatment improves short-term abstinence by reducing withdrawal distress or affecting the subjective effects of a lapse cigarette, but provided partial support for mediation by cigarette craving reduction and enhanced positive affect. Bupropion SR effects on point-prevalence abstinence at 1 month post-quit were also mediated partially by enhanced motivation to quit and self-efficacy. CONCLUSIONS Results provided some support for models of bupropion SR treatment and relapse and suggested that motivational processes may partially account for bupropion SR efficacy.

A Randomized Controlled Clinical Trial of Bupropion SR and Individual Smoking Cessation Counseling

Efficacy of bupropion SR and individual counseling as smoking cessation treatments was assessed in a randomized, placebo-controlled clinical trial among adult daily smokers. Bupropion SR treatment and counseling were fully crossed in this factorial design so that the efficacy of each treatment and the combination could be estimated, relative to a placebo medication and assessment control condition. Intent-to-treat analyses indicated that bupropion SR increased abstinence rates at the end of treatment, relative to the placebo medication conditions, for both biochemically confirmed 7-day point-prevalence abstinence (OR = 1.97, 95% CI 1.04-3.72) and self-reported prolonged abstinence (OR = 2.90, 95% CI 1.66-5.06). Bupropion SR treatment also improved latency to lapse and relapse and improved the latency between lapse and relapse in survival analyses. Medication effects were more modest for both 12-month point-prevalence abstinence (OR = 1.47, 95% CI 0.74-2.92) and prolonged abstinence (OR = 1.34, 95% CI 0.66-2.72). Counseling was not associated with increases in the likelihood of abstinence at any time point (odds ratios ranged from 0.80 to 1.16 across abstinence outcomes in the full intent-to-treat sample). Counseling and medication did not significantly interact at any time point, and adding counseling did not improve end-of-treatment point-prevalence abstinence (OR = 1.17, 95% CI 0.68-2.03) or prolonged abstinence (OR = 1.26, 95% CI 0.75-2.12) substantially when offered in conjunction with active medication.

Efficacy of Bupropion Alone and in Combination with Nicotine Gum

In this double-blind, placebo-controlled smoking cessation treatment study, 608 participants were randomly assigned to receive active bupropion and active 4-mg gum (AA, n = 228), active bupropion and placebo gum (AP, n = 224), or placebo bupropion and placebo gum (PP, n = 156). Relative to the PP group, the AA and AP groups were each significantly more likely to be abstinent at 1 week, end of treatment, and 6 months but not at 12 months postquit. After the first week postquit there were no differences in abstinence rates between the AA and AP groups. We found no significant individual difference variables that moderated outcome beyond 1 week postquit.