William G. Shadel

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.

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.

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.

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.

Analyzing Milestones in Smoking Cessation: Illustration in a Nicotine Patch Trial in Adult Smokers

Tests of addiction treatments seldom reveal where treatment exercises its effect (i.e., promoting initial abstinence, preventing lapses, and/or impeding progression from lapse to relapse). The authors illustrate analyses distinguishing effects on these milestones in a randomized trial of high-dose nicotine patch (35 mg; n = 188) versus placebo (n = 136) in adult smokers, who used electronic diaries to monitor smoking in real time during 5 weeks of treatment. High-dose patch promoted initial abstinence (hazard ratio [HR] = 1.3) and decreased the risk of lapsing among those who achieved abstinence (HR = 1.6). The biggest effect of treatment was to prevent progression to relapse among those who had lapsed (HR = 7.1). Analysis of effects by milestones may enhance understanding of cessation treatments and their mechanisms of action.

Response to social stress, urge to smoke, and smoking cessation

Motivational theories of drug use have assigned negative affect a central role in determining drug urges and drug relapse. The purpose of this study was to examine the effects of social stress on smoking urges in a controlled laboratory setting, and the relation of these responses to short-term (3-month) smoking cessation outcomes. Prior to a clinic-based smoking cessation program, 76 (64% female) smokers were assessed for their affective, cognitive, and physiological responses during the Borkovec social anxiety induction procedure. These responses were used to predict smoking urges immediately after the procedure and to predict abstinence at 3-month follow-up posttreatment. As expected, during the induction, urge to smoke was positively associated with anxiety ratings and negatively associated with self-efficacy to resist smoking. However, only heart rate increase and behavioral social skill (observed by independent judges) predicted smoking abstinence at 3 months. These results suggest that subjective affective and efficacy responses during a stressful social encounter are associated with smoking urges; however, urges and these responses may be related in different ways to the probability of smoking cessation.

Efficacy of acute administration of nicotine gum in relief of cue-provoked cigarette craving

RationaleAcute cravings, often provoked by exposure to smoking cues, appear to be important triggers for smoking relapse. Relief of acute craving may therefore be an important step in preventing relapse.ObjectivesThis study was undertaken to assess the effectiveness of nicotine gum in relieving acute craving.MethodsA multi-center, randomized, placebo-controlled study was conducted with smokers (n=296) who quit by using either active or inactive gum for 3xa0days. On their third day of abstinence, smokers participated in a laboratory session in which they were exposed to a provocative smoking cue, chewed active or inactive gum, and then rated their craving at 5-min intervals for 35xa0min.ResultsCraving initially decreased in both groups. After 15xa0min, however, the smokers using active nicotine gum experienced significantly greater craving reductions.ConclusionsThese results suggest that nicotine gum can effectively reduce acute craving following exposure to smoking cues.

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.

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.

Reduction of abstinence-induced withdrawal and craving using high-dose nicotine replacement therapy

RationaleDecreasing withdrawal and craving during smoking cessation is a major aim of cessation medications. Prior studies have shown that Nicotine Replacement Therapy (NRT) decreases withdrawal symptom severity but have relied on retrospective reports and lacked robust measures of baseline symptoms or symptoms during unmedicated abstinence.Objectives and methodsWe tested the effect of high-dose (35xa0mg) nicotine patch on withdrawal and craving during abstinence using real-time assessment with electronic diaries during ad libitum smoking, a brief period of experimentally directed trial abstinence, and the first 3xa0days of cessation. Subjects were 324 smokers randomized to high-dose nicotine patches or placebo.ResultsTreatment with active patches reduced withdrawal and craving during cessation and completely eliminated deprivation-related changes in affect or concentration.ConclusionHigh-dose NRT reduces withdrawal symptoms and craving and can eliminate some symptoms entirely.