Julie C. Gass

A Systematic Review of the Relationships Between Craving and Smoking Cessation

INTRODUCTION Craving is often portrayed as a defining feature of addiction, but the role of craving in the addictive process is controversial. Particularly contentious is the extent to which drug craving predicts subsequent relapse. METHODS This review synthesizes findings from 62 smoking cessation studies published through December 2011. Eligible studies measured craving for cigarettes in treatment-seeking smokers and related this to subsequent smoking status. The relationships of general craving and cue-specific craving with treatment outcome were examined separately. Further, analyses that related general craving to smoking status were divided into those that used craving data collected before the quit attempt, after the quit attempt, and those that used change in craving over time as a predictor. RESULTS Results across studies revealed a total of 198 indices of association with 94 (47%) of these being significant. In general, the findings indicated (a) there were only a few cases of significant associations between craving collected as part of cue-reactivity studies and treatment outcome, (b) postquit craving was a stronger predictor of treatment outcome than prequit craving, and (c) several moderators likely influence the relationship between craving and cessation outcome. CONCLUSIONS The overall results suggest that craving is not a necessary condition of relapse. In addition, inconsistent relationships between craving and treatment outcome call into question the value of craving as a target of treatment and underscore limitations in the prognostic utility of craving.

The relationship between craving and tobacco use behavior in laboratory studies: A meta-analysis.

Published laboratory studies from the last 50 years that included measures of craving and tobacco-consumption or tobacco-seeking measures were included in a meta-analysis in order to assess the relationship between craving and tobacco use. Seeking measures were further subdivided into those that reflected control by nonautomatic and automatic cognitive processes. Of 2,498 articles identified by the initial literature review, 204 analyses from 50 studies were deemed eligible. Overall, the relationship between craving and outcome behaviors was modest (r = .20, p < .001). Studies that imposed abstinence during data collection showed a stronger relationship between craving and outcome (r = .24, p < .001) than studies that did not (r = .18, p < .001). Further, of those studies that reported dependence, the overall association between craving and outcome was stronger for smokers who were less dependent. Separate meta-analyses revealed that the type of outcome measure moderated the omnibus effect, with the relationship between craving and nonautomatic seeking measures (r = .34, p < .001) being stronger than the relationship between craving and automatic seeking/consumption measures (both rs = 0.15, p < .001). These findings suggest that craving may play a role in, but does not fully account for, tobacco-use behaviors; furthermore, the extent to which craving predicts behavior may be increased when the behavior is under nonautomatic cognitive control.

Impact of varenicline on cue-specific craving assessed in the natural environment among treatment-seeking smokers

RationaleVarenicline is believed to work, in part, by reducing craving responses to smoking cues and by reducing general levels of craving; however, these hypotheses have never been evaluated with craving assessed in the natural environments of treatment-seeking smokers.ObjectivesEcological momentary assessment procedures were used to assess the impact of varenicline on cue-specific and general craving in treatment-seeking smokers prior to quitting.MethodsFor 5 weeks prior to quitting, 60 smokers carried personal digital assistants that assessed their response to smoking or neutral cues. During week 1 (baseline), participants did not receive medication; during weeks 2–4 (drug manipulation), participants were randomized to receive varenicline or placebo; during week 5 (standard therapy), all participants received varenicline. Craving was assessed before each cue; cue-specific craving and attention to cue were assessed after each cue.ResultsDuring all phases, smoking cues elicited greater craving than neutral cues; the magnitude of this effect declined after the first week. General craving declined across each phase of the study. Relative to the placebo condition, varenicline was associated with a greater decline in general craving over the drug manipulation phase. Varenicline did not significantly attenuate cue-specific craving during any phase of the study.ConclusionsSmoking cues delivered in the natural environment elicited strong craving responses in treatment-seeking smokers, but cue-specific craving was not affected by varenicline administered prior to the quit attempt. These findings suggest that the clinical efficacy of varenicline is not mediated by changes in cue-specific craving during the pre-quit period of treatment-seeking smokers.

The magnitude and reliability of cue-specific craving in nondependent smokers.

BACKGROUND Cue-reactivity is a robust phenomenon in regular cigarette smokers (Carter and Tiffany, 1999), but it has not been widely investigated in nondependent smokers. Further, most research on cue-specific craving assesses response to cues in a single experimental session. As such, investigations of cue-specific craving have primarily measured state-like but not trait-like responses to smoking stimuli. METHODS This study measured general and cue-specific craving in nondependent smokers and assessed the within-session and cross-session reliability of these two facets of craving. Participants (n=154) attended five laboratory sessions over the course of three months and completed multiple cue-reactivity trials (using smoking and neutral in vivo and photographic stimuli) during each study visit. RESULTS Results indicated that smoking cues elicited significantly stronger craving than neutral cues across study sessions, and that craving ratings following smoking cues decreased across subsequent sessions. Within-session and cross-session reliability was extremely high. CONCLUSIONS Overall, findings indicate that nondependent smokers experience reactivity to smoking cues, and that this response is quite reliable within and across sessions. Further, the magnitude of cue-specific craving was comparable to what has been observed in heavy, dependent smokers.

Diagnostic Utility of Craving in Predicting Nicotine Dependence: Impact of Craving Content and Item Stability

INTRODUCTION Craving is useful in the diagnosis of drug dependence, but it is unclear how various items used to assess craving might influence the diagnostic performance of craving measures. This study determined the diagnostic performance of individual items and item subgroups of the 32-item Questionnaire on Smoking Urges (QSU) as a function of item wording, level of craving intensity, and item stability. METHODS Nondaily and daily smokers (n = 222) completed the QSU on 6 separate occasions, and item responses were averaged across the administrations. Nicotine dependence was assessed with the Wisconsin Inventory of Smoking Dependence Motives. The discriminative performance of the QSU items was evaluated with receiver-operating characteristic curves and area under the curve statistics. RESULTS Although each of the QSU items and selected subgroups of items significantly discriminated dependent from nondependent smokers, certain item subgroups outperformed others. There was no difference in discriminative performance between use of the specific terms urge and crave or between items assessing intention to smoke relative to those assessing desire to smoke, but there were significant differences in the two major factors represented on the QSU and in craving items reflecting more intense relative to less intense craving. Stability of the item scores was strongly related to the discriminative performance of craving. CONCLUSIONS Items indexing stable, high-intensity aspects of craving that reflect the negative reinforcing effects of smoking will likely be most useful for diagnostic purposes. Future directions and implications are discussed.

Identifying measurement-based care practices of VHA co-located collaborative care providers.

The use of measurement-based care (MBC) is a routinely accepted practice in medical settings as a means to assess health status and guide evidence-based interventions. The continued expansion of integrated primary care within the Veterans Health Administration (VHA) offers ongoing opportunities for co-located collaborative care (CCC) providers to implement MBC. The present study aimed to identify and describe the degree to which MBC is used by CCC providers across VHA clinics in Upstate New York. A retrospective chart review of 448 CCC encounters was evaluated for evidence of MBC practices, including the use of quantitative mental health symptom screening tools, brief mental health symptom measures, and standardized functional assessment tools. Evidence of nonstandardized, idiographic assessments was also recorded. Providers’ use of measurement data to guide treatment initiation, modification, and termination was coded when available. Descriptive statistics were calculated for variables of interest. Results indicated that approximately 61% of patients were formally screened or completed mental health measures at least once during their course of care, though repeat administrations were rare. Detailed chart reviews found overall limited use of mental health screens and brief symptom measures (9.8% and 9.2% of all encounters, respectively), with measurement data infrequently (8.5%) linked to specific documented treatment decisions. Consistent with prior studies, CCC providers typically did not evidence use of standardized measures but did routinely record estimates of subjective distress and global functioning, lethality risk, and idiographic functional assessments. Obstacles and facilitators to the broader promotion and use of MBC among CCC providers are discussed.

Selection criteria limit generalizability of smoking pharmacotherapy studies differentially across clinical trials and laboratory studies: A systematic review on varenicline

BACKGROUND The selection criteria used in clinical trials for smoking cessation and in laboratory studies that seek to understand mechanisms responsible for treatment outcomes may limit their generalizability to one another and to the general population. METHODS We reviewed studies on varenicline versus placebo and compared eligibility criteria and participant characteristics of clinical trials (N=23) and laboratory studies (N=22) across study type and to nationally representative survey data on adult, daily USA smokers (2014 National Health Interview Survey; 2014 National Survey on Drug Use and Health). RESULTS Relative to laboratory studies, clinical trials more commonly reported excluding smokers who were unmotivated to quit and for specific medical conditions (e.g., cardiovascular disease, COPD), although both study types frequently reported excluding for general medical or psychiatric reasons. Laboratory versus clinical samples smoked less, had lower nicotine dependence, were younger, and more homogeneous with respect to smoking level and nicotine dependence. Application of common eligibility criteria to national survey data resulted in considerable elimination of the daily-smoking population for both clinical trials (≥47%) and laboratory studies (≥39%). Relative to the target population, studies in this review recruited participants who smoked considerably more and had a later smoking onset age, and were under-representative of Caucasians. CONCLUSIONS Results suggest that selection criteria of varenicline studies limit generalizability in meaningful ways, and differences in criteria across study type may undermine efforts at translational research. Recommendations for improvements in participant selection and reporting standards are discussed.

The Reliability and Stability of Puff Topography Variables in Non-Daily Smokers Assessed in the Laboratory

INTRODUCTION Puff topography variables, often measured using the Clinical Research Support System device, have traditionally been studied in regular, daily smokers and have been shown to be highly stable. However, more recent research has focused on non-daily smokers as a population of interest. As such, the aim of this article was to examine puff topography stability (cross-cigarette agreement over time) and reliability (within-cigarette consistency) in non-daily smokers across six laboratory sessions. METHODS One hundred seven non-daily smokers attended six laboratory sessions over the course of 3 months. At each session, they smoked one cigarette through the Clinical Research Support System pocket, in addition to completing questionnaires about their smoking history and dependence. RESULTS Puff topography measurements were highly reliable (α values ranged from 0.87-0.95) and puff behavior was highly stable across sessions (r values ranged from 0.38-0.84). Adding sessions substantially improved reliability estimates. Aspects of puffing behavior observed in session, including puff volume, puff duration, time of puff peak, and total cigarette volume were related to level of smoke exposure, measured by expired carbon monoxide. Instability in puffing behavior was not predicted by recent or long-term smoking patterns. CONCLUSIONS Puff topography appears to be a stable and routinized aspect of smoking in non-daily smokers. The feasibility of assessing puff topography in this population is supported by the high reliabilities observed, though it should be noted that reliability greatly improved by having more than one session.

Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia

ABSTRACT Objectives: Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period. Methods: Qualitative directed content analysis of retrospective EMR data. Results: Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers. Conclusion: Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care. Clinical Implications: The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.

Craving and tobacco use: Development of the choice behavior under cued conditions (CBUCC) procedure.

Many addiction theories propose that craving modulates smoking. Research on this relationship has yielded mixed results, which might be explained, in part, by a consideration of the various behaviors representing tobacco use. Tobacco use can be divided into seeking (attempts to access cigarettes) and consumption (ingestion of tobacco). Seeking can be further divided into behaviors that reflect the operation of automatic or nonautomatic cognitive processes. We developed a procedure (Choice Behavior Under Cued Conditions) to systematically examine the relationships between craving and these behaviors. Over multiple trials, thirty dependent smokers were exposed to a lit cigarette or a cup of water located behind a locked glass door. On each trial, participants rated craving and indicated the amount of money (