Jessica W. Cook

The Multiphase Optimization Strategy for Engineering Effective Tobacco Use Interventions

The multiphase optimization strategy (MOST) is a new methodological approach for building, optimizing, and evaluating multicomponent interventions. Conceptually rooted in engineering, MOST emphasizes efficiency and careful management of resources to move intervention science forward steadily and incrementally. MOST can be used to guide the evaluation of research evidence, develop an optimal intervention (the best set of intervention components), and enhance the translation of research findings, particularly type II translation. This article uses an ongoing study to illustrate the application of MOST in the evaluation of diverse intervention components derived from the phase-based framework reviewed in the companion article by Baker et al. (Ann Behav Med, in press, 2011). The article also discusses considerations, challenges, and potential benefits associated with using MOST and similar principled approaches to improving intervention efficacy, effectiveness, and cost-effectiveness. The applicability of this methodology may extend beyond smoking cessation to the development of behavioral interventions for other chronic health challenges.

Anxiety Diagnoses in Smokers Seeking Cessation Treatment: Relations with Tobacco Dependence, Withdrawal, Outcome, and Response to Treatment

AIMS To understand the relations among anxiety disorders and tobacco dependence, withdrawal symptoms, response to smoking cessation pharmacotherapy and ability to quit smoking. DESIGN Randomized placebo-controlled clinical trial. Participants received six 10-minute individual counseling sessions and either: placebo, bupropion SR, nicotine patch, nicotine lozenge, bupropion SR + nicotine lozenge or nicotine patch + nicotine lozenge. SETTING Two urban research sites. PARTICIPANTS Data were collected from 1504 daily smokers (>9 cigarettes per day) who were motivated to quit smoking and did not report current diagnoses of schizophrenia or psychosis or bupropion use. MEASUREMENTS Participants completed baseline assessments, the Composite International Diagnostic Interview and ecological momentary assessments for 2 weeks. FINDINGS A structured clinical interview identified participants who ever met criteria for a panic attack (n = 455), social anxiety (n = 199) or generalized anxiety disorder (n = 99), and those who qualified for no anxiety diagnosis (n = 891). Smokers with anxiety disorders reported higher levels of nicotine dependence and pre-quit withdrawal symptoms. Those ever meeting criteria for panic attacks or social anxiety disorder showed greater quit-day negative affect. Smokers ever meeting criteria for anxiety disorders were less likely to be abstinent at 8 weeks and 6 months post-quit and showed no benefit from single-agent or combination-agent pharmacotherapies. CONCLUSIONS Anxiety diagnoses were common among treatment-seeking smokers and were related to increased motivation to smoke, elevated withdrawal, lack of response to pharmacotherapy and impaired ability to quit smoking. These findings could guide treatment assignment algorithms and treatment development for smokers with anxiety diagnoses.

Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials

INTRODUCTION Smoking is the leading preventable cause of morbidity and mortality in the United States, but this burden is not distributed equally among smokers. Women, Blacks, and people with low socioeconomic status are especially vulnerable to the health risks of smoking and are less likely to quit. METHODS This research examined cessation rates and treatment response among 2,850 participants (57.2% women, 11.7% Blacks, and 9.0% with less than a high school education) from two large cessation trials evaluating: nicotine patch, nicotine lozenge, bupropion, bupropion + lozenge, and nicotine patch + lozenge. RESULTS Results revealed that women, Blacks, and smokers with less education were less likely to quit smoking successfully than men, Whites, and smokers with more education, respectively. Women did not appear to benefit more from bupropion than from nicotine replacement therapy, but women and smokers with less education benefited more from combination pharmacotherapy than from monotherapy. DISCUSSION Women, Blacks, and smokers with less education are at elevated risk for cessation failure, and research is needed to understand this risk and develop pharmacological and psychosocial interventions to improve their long-term cessation rates.

New methods for tobacco dependence treatment research

IntroductionDespite advances in tobacco dependence treatment in the past two decades, progress has been inconsistent and slow. This paper reviews pervasive methodological issues that may contribute to the lack of timely progress in tobacco treatment science including the lack of a dynamic model or framework of the cessation process, inefficient study designs, and the use of distal outcome measures that poorly index treatment effects. The authors then present a phase-based cessation framework that partitions the cessation process into four discrete phases based on current theories of cessation and empirical data. These phases include: (1) Motivation, (2) Precessation, (3) Cessation, and (4) Maintenance.DiscussionWithin this framework, it is possible to identify phase-specific challenges that a smoker would encounter while quitting smoking, intervention components that would address these phase-specific challenges, mechanisms via which such interventions would exert their effects, and optimal outcome measures linked to these phase-specific interventions. Investigation of phase-based interventions can be accelerated by using efficient study designs that would permit more timely development of an optimal smoking cessation treatment package.

Impulsivity and cigarette craving: differences across subtypes

RationaleCigarette smoking has been linked to a number of personality characteristics, including impulsivity. Smokers tend to endorse high levels of impulsivity, and more impulsive smokers have greater difficulty quitting, but little is known about potential explanatory mechanisms. Although indirect evidence suggests craving as a candidate mechanism, direct evidence has been mixed.Materials and methodsThis study assessed whether specific aspects of impulsivity (sensation seeking, lack of premeditation, lack of perseverance, and urgency) were associated with cue-induced craving. Regular smokers (n = 60; 50% female) were exposed to a smoking cue and a neutral cue in a repeated measure counter-balanced design.ResultsMixed effects regression models indicated that smokers who were high in sensation seeking reported greater increases in appetitive craving after smoking cue exposure, whereas, smokers who were high in urgency and lack of perseverance reported greater increases in negative affect craving.ConclusionsFindings suggest a complex relationship between impulsivity and cue-induced craving that may be masked by single construct conceptualizations of impulsivity.

Effects of anhedonia on days to relapse among smokers with a history of depression: A brief report

INTRODUCTION Despite the strong co-occurrence between lifetime prevalence of depression and smoking, a history of major depressive disorder (MDD history) does not reliably predict smoking cessation outcomes. However, depression is a heterogeneous syndrome comprising several dimensions (e.g., anhedonia, vegetative symptoms, negative affect), and each symptom expression may differentially influence cessation failure. Measuring proximal depressive dimensions may provide a more reliable way of identifying MDD history smokers most at risk for smoking relapse. Anhedonia, in particular, is a core feature of depression that may increase risk for smoking relapse among MDD history smokers. The primary goal of the present study was to investigate the relation between anhedonia and relapse latency among MDD history smokers following a brief smoking cessation workshop. METHODS Participants (N = 45, 48.9% female), who were euthymic regular smokers with a history of MDD, were randomized to 1 of 3 treatment groups that all involved participation in a daylong group workshop. Workshops were followed by 48 hr of bioverified abstinence and weekly follow-up visits for 1 month. RESULTS Cox proportional hazard modeling was used to evaluate the effect of anhedonia on relapse latency 30 days following quitting smoking. Results showed that higher levels of anhedonia predicted reduced relapse latencies, both with and without prequit depressive symptom severity included in the model. DISCUSSION Results suggest that anhedonia may constitute a proximal risk factor identifying depressive history smokers more likely to relapse to smoking.

Influence of PTSD symptom clusters on smoking status among help-seeking Iraq and Afghanistan veterans.

INTRODUCTION Despite the strong association between smoking and posttraumatic stress disorder (PTSD), mechanisms influencing smoking in this population remain unclear. Previous smoking research has largely examined PTSD as a homogenous syndrome despite the fact that PTSD is composed of four distinct symptom clusters (i.e., reexperiencing, effortful avoidance, emotional numbing, and hyperarousal). Examination of the relationship between smoking and PTSD symptom clusters may increase understanding of mechanisms influencing comorbidity between smoking and PTSD. The goals of the present study were to (a) examine the influence of overall PTSD symptom severity on likelihood of smoking and smoking heaviness and (b) examine the influence of each PTSD symptom cluster on smoking. METHODS Participants (N = 439) were Operation Iraqi Freedom/Operation Enduring Freedom combat veterans referred to VA mental health services. RESULTS Multinomial logistic regression was chosen to accommodate a three-level outcome, in which the likelihood of being a nonsmoker was compared with (a) light smoking (1-9 cigarettes/day), (b) moderate smoking (10-19 cigarettes/day), and (c) heavy smoking (> or =20 cigarettes/day). Results showed that veterans with higher levels of overall PTSD symptomatology were more likely to endorse heavy smoking (Wald = 4.56, p = .03, odds ratio [OR] = 1.65). Veterans endorsing high levels of emotional numbing were also more likely to endorse heavy smoking (Wald = 6.49, p = .01, OR = 1.81); all other PTSD symptom clusters were unrelated to smoking. DISCUSSION The association between emotional numbing and heavy daily smoking suggests that veterans with PTSD may smoke to overcome emotional blunting following trauma exposure.

Anhedonia, depressed mood, and smoking cessation outcome.

OBJECTIVE Although the relation between lifetime depression and smoking cessation outcome has been well studied, the proposition that different symptomatic expressions of depression exert disparate predictive effects on risk of smoking cessation failure has largely gone uninvestigated. This study analyzed the individual contributions of depressions 2 hallmark affective symptoms, anhedonia (i.e., diminished interest in normally enjoyable activities) and depressed mood (i.e., elevated sadness), to the prediction of smoking cessation outcome. METHOD Participants were adult daily smokers (N = 1,469; mean age = 45 years, 58% female, 84% White) enrolled in a smoking cessation treatment study. Lifetime history of anhedonia and depressed mood were classified via structured interview prior to quit day. Seven-day point prevalence smoking abstinence was assessed at 8 weeks and 6 months postquit. RESULTS When examined separately, both lifetime anhedonia, OR (95% CI) = 1.42 (1.16, 1.73), p = .004, and depressed mood, OR (95% CI) = 1.35 (1.11, 1.63), p = .002, predicted increased odds of relapse. These relations remained after adjusting for covariates, including lifetime depressive disorder, which did not predict outcome. After controlling for the covariation between lifetime anhedonia and depressed mood, anhedonia predicted cessation outcome, OR (95% CI) = 1.31 (1.05, 1.62), p = .02, while depressed mood did not (p = .19). Symptom duration (>2 weeks), treatment, and substance use disorder did not modify relations of lifetime anhedonia and depressed mood with cessation outcome. CONCLUSIONS Results suggest that (1) symptoms of affective disturbance capture depression-relevant risk of cessation failure, which is not adequately demarcated by the lifetime depressive disorder diagnosis, and (2) anhedonia is a more sensitive index of this affective disturbance than depressed mood per se. Clinical attention to anhedonia may facilitate smoking cessation.

Cigarette smoking and depression comorbidity: systematic review and proposed theoretical model

BACKGROUND AND AIMS Despite decades of research on co-occurring smoking and depression, cessation rates remain consistently lower for depressed smokers than for smokers in the general population, highlighting the need for theory-driven models of smoking and depression. This paper provides a systematic review with a particular focus upon psychological states that disproportionately motivate smoking in depression, and frame an incentive learning theory account of smoking-depression co-occurrence. METHODS We searched PubMed, Scopus, PsychINFO and CINAHL to December 2014, which yielded 852 papers. Using pre-established eligibility criteria, we identified papers focused on clinical issues and motivational mechanisms underlying smoking in established, adult smokers (i.e. maintenance, quit attempts and cessation/relapse) with elevated symptoms of depression. Two reviewers determined independently whether papers met review criteria. We included 297 papers in qualitative synthesis. RESULTS Our review identified three primary mechanisms that underlie persistent smoking among depressed smokers: low positive affect, high negative affect and cognitive impairment. We propose a novel application of incentive learning theory which posits that depressed smokers experience greater increases in the expected value of smoking in the face of these three motivational states, which promotes goal-directed choice of smoking behavior over alternative actions. CONCLUSIONS The incentive learning theory accounts for current evidence on how depression primes smoking behavior and provides a unique framework for conceptualizing psychological mechanisms of smoking maintenance among depressed smokers. Treatment should focus upon correcting adverse internal states and beliefs about the high value of smoking in those states to improve cessation outcomes for depressed smokers.

Anhedonia as a Component of the Tobacco Withdrawal Syndrome

Animal research suggests that anhedonia is a tobacco withdrawal symptom, but this topic has not been addressed definitively in research with humans. This research sought to determine whether anhedonia is (a) an element of the tobacco withdrawal syndrome in humans and (b) an impediment to successful tobacco cessation. Data were from 1,175 smokers (58.3% women; 85.5% White) participating in a randomized double-blind, placebo-controlled trial of smoking cessation pharmacotherapies. Ecological momentary assessments for 5 days before and 10 days after the target quit day were used to assess anhedonia and other established withdrawal symptoms. Consistent with drug withdrawal, anhedonia showed an inverted-U pattern of change in response to tobacco cessation and was associated with the severity of other withdrawal symptoms and tobacco dependence. Postquit anhedonia was associated with decreased latency to relapse (hazard ratio = 1.09, 95% confidence interval [CI] [1.02, 1.17]) and with lower 8-week point-prevalence abstinence (odds ratio = .91, 95% CI [.86, .97])-relations that remained significant when other withdrawal symptoms were included as predictors. Finally, nicotine replacement therapy nearly fully suppressed the increase in abstinence-related anhedonia (β = -.66, p < .001), suggesting agonist suppression of withdrawal. Results suggest that anhedonia is a unique and motivationally significant element of the tobacco withdrawal syndrome in humans. These results have implications for defining and assessing tobacco use disorder and for understanding and treating tobacco addiction.