Point process analyses of variations in smoking rate by setting, mood, gender, and dependence

Reactivity to Smoking Cues in a Social Context: Virtual Reality Experiment

Background

Social contextual factors influence the onset and maintenance of substance abuse. Virtual reality (VR) provides a standardized method to present social stimuli and is increasingly used in addiction research.

Objective

This study examines the influence of a smoking versus a nonsmoking agent in VR on craving in nicotine-dependent male participants. Our primary hypothesis was that the interaction with a smoking agent is associated with increased craving compared to a nonsmoking agent. We expected higher craving in the presence of an agent regardless of the agent's smoking status.

Methods

Using a head-mounted display (Oculus Rift), 50 nicotine-dependent smokers were exposed to four VR conditions on a virtual marketplace: first without an agent, second and third with an agent who either smoked or did not smoke in randomized order, and fourth without an agent as a follow-up condition. Before the follow-up condition, participants smoked a cigarette. Craving was assessed with the Questionnaire of Smoking Urges and a visual analog scale within VR and after each session. We also examined anxiety and agitation (visual analog scale), immersion and presence with the igroup Presence Questionnaire, and salivary cortisol levels.

Results

Results showed no significant difference in the participants' craving, anxiety, or agitation between the smoking and nonsmoking agent conditions. However, craving, anxiety, and agitation increased from the marketplace without an interacting agent to the conditions with an interacting agent, and decreased after smoking a cigarette. Immersion was low in all conditions and decreased over time. Salivary cortisol levels were highest at baseline and decreased over the course of the experiment.

Conclusions

These findings suggest that the presence of an agent (as a contextual factor) may override the specific influence of proximal stimuli (burning cigarette). The low immersion highlights the challenges in developing effective VR environments for cue exposure.

Dynamical System Modeling of Self-Regulated Systems Undergoing Multiple Excitations: First Order Differential Equation Approach

This article proposes a dynamical system modeling approach for the analysis of longitudinal data of self-regulated homeostatic systems experiencing multiple excitations. It focuses on the evolution of a signal (e.g., heart rate) before, during, and after excitations taking the system out of its equilibrium (e.g., physical effort during cardiac stress testing). Such approach can be applied to a broad range of outcomes such as physiological processes in medicine and psychosocial processes in social sciences, and it allows to extract simple characteristics of the signal studied. The model is based on a first order linear differential equation with constant coefficients defined by three main parameters corresponding to the initial equilibrium value, the dynamic characteristic time, and the reaction to the excitation. Assuming the presence of interindividual variability (random effects) on these three parameters, we propose a two-step procedure to estimate them. We then compare the results of this analysis to several other estimation procedures in a simulation study that clarifies under which conditions parameters are accurately estimated. Finally, applications of this model are illustrated using cardiology data recorded during effort tests.

The Gender-Sensitive Social Risk Factors for Internet Addiction in College Undergraduate Students

OBJECTIVE

The current study aims to explore precipitating and social risk factors for internet addiction (IA) in university undergraduate students, and to provide evidence for interventions and the early prevention of IA in different genders.

METHODS

Four thousand eight hundred and fifty-eight college sophomores completed an online survey on their internet use-related behaviours and social risk factors.

RESULTS

We found that more male (8.3%) than female students (5.4%) had moderate and severe IA. The main online activity in the moderate and severe IA groups was online gaming in males and online streaming in females. Roommates engaging in similar internetbased entertainment was a risk factor of IA only for males, while not being in a romantic relationship was a risk factor of IA for females only. Infatuation with the internet before college and adjustment problems for college life were shared risk factors for both genders in the mild and moderate IA groups.

CONCLUSION

IA was a common phenomenon in college students with shared and unique precipitating and social risk factors in males and females. The gender-sensitive risk factors for IA warranted earlier and individualized intervention and prevention strategies for IA in this population.

COVID-19 Impact on Smokers Participating in Smoking Cessation Trials: The Experience of Nondaily Smokers Participating in a Smartphone App Study

Objectives: To provide initial insight into how the COVID-19 pandemic could affect smoking behaviors and cessation efforts that were underway at its onset. Methods: An additional survey was added to follow-up assessments in an ongoing smoking cessation study for nondaily smokers: a measure of impact of COVID-19 and a subset of previously administered scales measuring smoking, emotional well-being, and alcohol use. Pre-post tests were conducted (84 ± 28 days apart). Results: Participants (81/100 of enrolled; 67% female, 75% white, 10% Hispanic, 37 ± 11 years old) reported experiencing changes regarding work (35% income reduction/loss; 35% remote work) and living situation (15% consolidated residences). Participants reported their motivation to quit smoking "slightly" increased after COVID-19 (p < 0.001), more so in those having achieved 30-day abstinence (p = 0.0045). Worry, fear, and a desire to support the greater good increased (ps < 0.05). Increases in motivation to quit correlated positively with prosocial and wellness changes. Data from pre- to post-COVID-19 onset showed decreases in emotional well-being (increased stress, negative affect, decreased coping, positive affect, all ps < 0.01), but not changes in smoking abstinence (p = 0.65), readiness to quit (p = 0.16), smoking frequency (p = 0.96), or cigarettes per day (p = 0.96). Heavy drinking decreased (p < 0.01). Trying e-cigarettes increased (p = 0.04). Conclusions: Nondaily smokers participating in a smoking cessation study during the COVID-19 pandemic reported worsened emotional well-being without effects on smoking outcomes and said their motivation to quit was slightly increased. Correlations of motivation to quit with prosocial and wellness changes suggest that targeting these constructs may be particularly helpful during a pandemic.

Efficacy of Osteoporosis Prevention Smartphone App

BACKGROUND

The Striving to be Strong study tested the efficacy of a multifaceted, theory-based, complex osteoporosis prevention smartphone application (app). We hypothesized use of the app would improve bone mineral density and trabecular bone scores.

METHODS

The study was a three-group, prospective, repeated-measure, longitudinal randomized trial. Baseline sample consisted of 290 healthy women between 40 and 60 years of age. Participants were randomly assigned to one of three groups: "Striving," a dynamically tailored, person-centered app; "Boning Up," a standardized osteoporosis-education e-book; and "Wait List," a participant's choice of intervention in the final 3 months of the 12-month study. Participants had or were provided a smart phone. Bone mineral density and trabecular bone scores were measured using dual-energy X-ray absorptiometry at baseline and 12 months. To assess engagement in health behavior change processes, ecological momentary assessments were administered via text messaging during the 12 months participants actively used the app.

RESULTS

The final sample reflects an 89.6% retention rate. There were decreases in bone mineral density over time but not among the three groups. The percentage of bone density lost over 12 months was lower than expected. Trabecular bone scores were not different over time or by group but improved across all three groups.

DISCUSSION

Small but positive results were observed across all groups, suggesting one or more aspects of participation might have affected outcomes, including dissemination of the intervention across groups, retention without participation, ecological momentary assessments functioning as both an intervention and measure, and selective engagement in research-based recommendations.

Sex Differences in Subjective and Behavioral Responses to Stressful and Smoking Cues Presented in the Natural Environment of Smokers

INTRODUCTION

Some evidence suggests that female smokers may show more context-dependent smoking and that males may show more stereotyped smoking (regardless of stress or cue exposure). The goal of this study was to characterize sex differences in response to stressful and smoking cues ecologically presented in daily life and variability in day-to-day smoking behavior.

METHODS

Adult smokers (N = 177) provided ratings of mood and cigarette craving before and after stress and smoking cues were presented four times daily for 14 days via a mobile device. Linear mixed models tested whether (1) female smokers exhibited greater reactivity to stressful cues than male smokers; (2) pre-cue negative affect increased reactivity to smoking cues more in female smokers than male smokers; (3) across both sexes, greater reactivity to stressful and smoking cues correlated with greater quantity of smoking within a day; and (4) female smokers exhibited greater variability in cigarettes per day (CPD) relative to males.

RESULTS

Relative to male smokers, female smokers reported greater negative affect, stress, and craving in response to stressful cues, but not smoking cues, after accounting for time since last cigarette and pre-cue responding. No sex differences in CPD or variability in CPD were detected. Days with higher subjective reactivity to cues were not associated with increased smoking, in either males or females.

CONCLUSIONS

Sex differences were observed in response to stress but not smoking cues in the natural environment of regular cigarette smokers. Further research is necessary to evaluate whether stress reactivity in female smokers is associated with reduced latency to smoke following stress exposure in daily life.

IMPLICATIONS

This study provides naturalistic evidence that female smokers may not be more reactive to smoking cues than males, but experience heightened stress and craving following stress exposure. There was no evidence to support the hypothesis that amount smoked per day varied more for females, relative to males, as a result of more context-driven smoking for females.

Depression as a moderator of the prospective relationship between mood and smoking

OBJECTIVE

Affective features of depression are uniquely involved in the depression-smoking relationship, and it follows that smokers with depression are likely to use cigarettes to alleviate negative affect. However, most ecological momentary assessment (EMA) studies demonstrate no relationship between mood and smoking, in general. Conversely, a small number of experimental studies suggest there is an association between mood and smoking and that the relationship is dependent on levels of depression. Researchers have yet to examine the impact of depression on the relationship between mood and smoking using EMA methodology. Accordingly, the aim of this study was to explore the relationship between depression, mood, and ad lib smoking among adults in "real time."

METHOD

Participants included 96 adult daily smokers (53% female, 67% non-Hispanic Black; age, M = 40.76, SD = 12.42) who completed baseline ratings of depressive symptoms and 7 consecutive days of in vivo data collection focused on cigarette smoking and associated mood and craving ratings.

RESULTS

Results indicated that depression moderates the prospective relationship between mood and smoking (even when controlling for craving), such that participants with higher levels of depressive symptoms smoke more cigarettes in response to an improvement in mood (relative to their average mood), whereas participants with lower levels of depressive symptoms smoke more in response to worsening mood states (relative to their average mood).

CONCLUSIONS

Attempting to maintain better mood may be a motivating factor for smoking among depressed individuals. These findings may be helpful in tailoring smoking cessation treatment programs for people exhibiting depressive symptoms. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Wearable Sensors for Monitoring of Cigarette Smoking in Free-Living: A Systematic Review

Globally, cigarette smoking is widespread among all ages, and smokers struggle to quit. The design of effective cessation interventions requires an accurate and objective assessment of smoking frequency and smoke exposure metrics. Recently, wearable devices have emerged as a means of assessing cigarette use. However, wearable technologies have inherent limitations, and their sensor responses are often influenced by wearers' behavior, motion and environmental factors. This paper presents a systematic review of current and forthcoming wearable technologies, with a focus on sensing elements, body placement, detection accuracy, underlying algorithms and applications. Full-texts of 86 scientific articles were reviewed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines to address three research questions oriented to cigarette smoking, in order to: (1) Investigate the behavioral and physiological manifestations of cigarette smoking targeted by wearable sensors for smoking detection; (2) explore sensor modalities employed for detecting these manifestations; (3) evaluate underlying signal processing and pattern recognition methodologies and key performance metrics. The review identified five specific smoking manifestations targeted by sensors. The results suggested that no system reached 100% accuracy in the detection or evaluation of smoking-related features. Also, the testing of these sensors was mostly limited to laboratory settings. For a realistic evaluation of accuracy metrics, wearable devices require thorough testing under free-living conditions.

Addiction and Dopamine: Sex Differences and Insights from Studies of Smoking

Mesolimbic dopaminergic function influences addiction through effects on reinforcement learning, decision-making, and impulsivity. This review covers sex differences in dopaminergic neurochemistry, their hormonal and genetic determinants, and how differences in dopaminergic tone interact with sex and/or ovarian hormone status to affect cognitive functions. Findings from research on cigarette smoking reveal sex differences in striatal and midbrain dopamine D2-type receptor availability and striatal dopamine release that suggest mechanisms of nicotine dependence, and stronger subjective responses to nicotine and efficacy of nicotine replacement therapies in male smokers than in their female counterparts. Opportunities exist to extend such efforts in studies of how sex and hormone status influence other addictions.

An Ecological Momentary Assessment of Cigarette and Cigar Dual Use Among African American Young Adults

Introduction

The dual use of cigarettes and cigars among African American young adults is a significant public health issue. Patterns of and reasons for dual use are difficult to capture using traditional self-report methods. This study used ecological momentary assessment (EMA) to characterize patterns of dual smoking and examine the personal and environmental predictors of cigarette and cigar smoking among African American young adult dual users (ages 18-29) in real-time.

Methods

For 14 days, 64 participants smoked ad libitum and were prompted four times daily to record their smoking, craving, emotions, social smoking, and environment via text message on their mobile phones. The odds of single product and dual use were examined using adjusted generalized estimating equations.

Results

Participants smoked an average of 7.9 cigarettes and 4.2 cigars per day. Cigarettes and cigars were smoked as frequently during periods of dual use as they were during periods of single product use. Cigarette craving was positively associated with cigarette-only smoking (OR: 1.07), whereas cigar craving was positively associated with cigar-only smoking (OR: 1.43) and dual use (OR: 1.08). Cigars had the greatest odds of dual use when with others (OR: 4.69) and in others' homes (OR: 4.33). Cigarettes had the greatest odds of being smoked while alone (OR: 1.57).

Conclusions

EMA was useful for capturing variable smoking patterns and predictors. In this study population, cigarettes and cigars appeared to be smoked additively, and cigars smoked socially. These findings can inform future interventions addressing dual use in this high priority population.

Implications

This is the first study to use EMA to examine naturalistic patterns and predictors of multiple tobacco use in real-time. African American young adults smoked cigarettes and cigars during periods of dual use as frequently as during periods of single product use. This suggests that most use was additive (one product smoked in addition to another) and less often as substitution (one product smoked instead of another). Social smoking and craving were strongly associated with cigar smoking in single and dual use periods. This study suggests the need for cessation messaging specifically targeted to reduce dual use in this population.

The case for investigating social context in laboratory studies of smoking

BACKGROUND

With increasing frequency, addiction is conceived of as a brain disease, and such accounts seem especially pertinent with regard to the rapid delivery of nicotine to the brain via cigarette smoke. Moreover, drug administration trials (cigarette puffs) suggest that the behavior of smoking becomes automatized, with individuals developing prototypical approaches to smoking a cigarette. Compared with presumably more social activities, such as drinking alcohol, there may be little opportunity for social processes to influence smoking behavior. However, survey research examining smoking motivation often reveals a broadly defined 'social' factor and field research suggests that social context does influence smoking.

ARGUMENT

We posit that laboratory smoking research has largely ignored social contextual factors that may help to understand better the precise mechanisms underlying smoking behavior and smoking motivation.

METHOD

We reviewed laboratory studies examining the effect of social context (operationalized as modeling) on smoking behavior. Studies were identified by searching PsychInfo and Medline using the following keywords: smoking, nicotine, tobacco, cigarette, consumption, topography, puff, smoking behavior, cigarettes smoked, modeling, imitation, social context, social influence and peer pressure. The reference and citation lists of these studies were then searched to identify additional studies.

CONCLUSIONS

Few laboratory smoking studies target social context. Those few studies indicate that smoking behavior can be influenced by the presence of others. There is also some evidence that social context influences the effects of smoking as well as processes related to self-perception and self-regulation that reinforce smoking and hamper smoking cessation efforts.

Classifying smoking urges via machine learning

BACKGROUND AND OBJECTIVE

Smoking is the largest preventable cause of death and diseases in the developed world, and advances in modern electronics and machine learning can help us deliver real-time intervention to smokers in novel ways. In this paper, we examine different machine learning approaches to use situational features associated with having or not having urges to smoke during a quit attempt in order to accurately classify high-urge states.

METHODS

To test our machine learning approaches, specifically, Bayes, discriminant analysis and decision tree learning methods, we used a dataset collected from over 300 participants who had initiated a quit attempt. The three classification approaches are evaluated observing sensitivity, specificity, accuracy and precision.

RESULTS

The outcome of the analysis showed that algorithms based on feature selection make it possible to obtain high classification rates with only a few features selected from the entire dataset. The classification tree method outperformed the naive Bayes and discriminant analysis methods, with an accuracy of the classifications up to 86%. These numbers suggest that machine learning may be a suitable approach to deal with smoking cessation matters, and to predict smoking urges, outlining a potential use for mobile health applications.

CONCLUSIONS

In conclusion, machine learning classifiers can help identify smoking situations, and the search for the best features and classifier parameters significantly improves the algorithms' performance. In addition, this study also supports the usefulness of new technologies in improving the effect of smoking cessation interventions, the management of time and patients by therapists, and thus the optimization of available health care resources. Future studies should focus on providing more adaptive and personalized support to people who really need it, in a minimum amount of time by developing novel expert systems capable of delivering real-time interventions.

Trajectories of smoking behavior as a function of mood and satisfaction with life: What matters most?

BACKGROUND

Worldwide, tobacco use causes more than 5 million deaths per year. The present study investigated possible preventative factors of nicotine dependence, such as mood and Satisfaction With Life (SWL).

METHODS

Longitudinal Internet survey of 1957 individuals assessed three times at a two week interval (2007-2010).

OUTCOME MEASURES

Cigarette Dependence Scale (CDS), feeling prisoner to cigarettes, smoking cessation, reduction, and relapse.

PREDICTORS

Time (i.e. trajectory of dependence over time), smoking status (daily, occasional or ex-smoker), mood, and SWL. All measures were assessed at each time point.

RESULTS

Both SWL, and mood, respectively were significantly associated with dependence (slopeSWL=-0.03, slopeSWL=-0.11, ps<0.001). With respect to feeling prisoner to cigarettes, mood but not SWL showed a significant association (slopeSWL=-0.14, p<0.001). Occasional, and ex-smokers showed significantly greater decrease in psychological dependence, as mood increased, than daily smokers (slopeoccasional=-0.28, poccasional=0.011; slopeex=-0.27, pex<0.001). Smoking cessation decreased over time, and both mood, as well as SWL had a significant impact on cessation (ORmood=1.43, pmood<0.01, ORSWL=1.15, pSWL=0.042). Reduction in smoking was predicted by SWL only (ORSWL=1.21, p=0.043), whereas relapse was predicted by mood only (ORmood=0.55, p<0.01).

LIMITATIONS

The participants were self-selected. Possible confounding relationships (e.g., medication) have to be further assessed.

CONCLUSIONS

Cigarette dependence, feeling prisoner to cigarettes, cessation, and reduction are significantly influenced by both mood and SWL. Treatments may thus tackle mood regulation, SWL, and nicotine dependence in tandem.

Mixed effects models for recurrent events data with partially observed time-varying covariates: Ecological momentary assessment of smoking

Cigarette smoking is a prototypical example of a recurrent event. The pattern of recurrent smoking events may depend on time-varying covariates including mood and environmental variables. Fixed effects and frailty models for recurrent events data assume that smokers have a common association with time-varying covariates. We develop a mixed effects version of a recurrent events model that may be used to describe variation among smokers in how they respond to those covariates, potentially leading to the development of individual-based smoking cessation therapies. Our method extends the modified EM algorithm of Steele (1996) for generalized mixed models to recurrent events data with partially observed time-varying covariates. It is offered as an alternative to the method of Rizopoulos, Verbeke, and Lesaffre (2009) who extended Steele's (1996) algorithm to a joint-model for the recurrent events data and time-varying covariates. Our approach does not require a model for the time-varying covariates, but instead assumes that the time-varying covariates are sampled according to a Poisson point process with known intensity. Our methods are well suited to data collected using Ecological Momentary Assessment (EMA), a method of data collection widely used in the behavioral sciences to collect data on emotional state and recurrent events in the every-day environments of study subjects using electronic devices such as Personal Digital Assistants (PDA) or smart phones.

Gender and stimulus control of smoking behavior

INTRODUCTION

Gender differences in smoking behavior have been proposed to account for poorer outcomes among women attempting to quit. Specifically, it has been suggested that women's smoking behavior is less motivated by nicotine-seeking and more driven by environmental cues. To date, however, few real-world studies have examined the hypothesis that women's smoking is under greater stimulus control.

METHODS

One hundred and ninety four daily smokers (men = 107; women = 87) completed 3 weeks of ecological momentary assessment (EMA) monitoring that provided data on real-world smoking behavior by reporting on situational contexts shown by previous research to influence smoking behavior (including social setting, cigarette availability, alcohol consumption, and mood).

RESULTS

Analyses of particular cues found few gender differences; however, men's smoking increased to a greater extent compared with women's when they were with others who were smoking. Idiographic analyses that allow individual subjects to have different directions of linkage to situational cues also were conducted to assess how predictable subjects' smoking was from a range of contextual characteristics. Compared with women, men's smoking was significantly more closely tied to food/alcohol consumption and tended to be more closely tied to social context. No other gender differences were found.

CONCLUSIONS

EMA analyses suggest that men and women are similarly influenced by cues, including mood. Where there were gender differences, it was men rather than women whose smoking behavior was more influenced by cues. The data contradict the hypothesis that women's smoking is more influenced by cues.

Ecological momentary assessment in the investigation of craving and substance use in daily life: a systematic review

BACKGROUND

Craving is viewed as a major determinant of relapse in persons with substance addiction, but this association remains poorly understood due to its time-limited nature and the biases associated with retrospective reporting. Ecological momentary assessment (EMA) offers new opportunities to examine both craving and substance use with strong ecological validity by collecting real-time data in daily life. This review examined all published studies using EMA to: (1) assess the link between craving and substance use; and (2) identify relevant moderators of craving among substance users.

METHODS

We searched PubMed and PsycInfo databases up to October 31, 2013.

RESULTS

Ninety-one studies were selected, involving mostly tobacco smokers (73%). A majority of studies (92%) reported a positive relationship between craving and substance use, concurrently and prospectively, and among users with different levels of use for both legal and illegal substances. Results suggest that craving is a stronger predictor of relapse episodes when assessed in close temporal proximity to substance use. EMA data also confirmed the influence of diverse within-person and between-person sources of variation in daily life craving reports.

CONCLUSIONS

This review provides strong support for the link between craving and substance use, and underscores the importance of the timing of assessments.

The relation between number of smoking friends, and quit intentions, attempts, and success: findings from the International Tobacco Control (ITC) Four Country Survey

Smokers who inhabit social contexts with a greater number of smokers may be exposed to more positive norms toward smoking and more cues to smoke. This study examines the relation between number of smoking friends and changes in number of smoking friends, and smoking cessation outcomes. Data were drawn from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control (ITC) Project Four Country Survey, a longitudinal cohort survey of nationally representative samples of adult smokers in Australia, Canada, United Kingdom, and United States (N = 6,321). Smokers with fewer smoking friends at Wave 1 were more likely to intend to quit at Wave 1 and were more likely to succeed in their attempts to quit at Wave 2. Compared with smokers who experienced no change in their number of smoking friends, smokers who lost smoking friends were more likely to intend to quit at Wave 2, attempt to quit between Wave 1 and Wave 2, and succeed in their quit attempts at Wave 2. Smokers who inhabit social contexts with a greater number of smokers may be less likely to successfully quit. Quitting may be particularly unlikely among smokers who do not experience a loss in the number of smokers in their social context.

Socioeconomic status and smokers' number of smoking friends: findings from the International Tobacco Control (ITC) Four Country Survey

BACKGROUND

Smoking rates are higher among low socioeconomic (SES) groups, and there is evidence that inequalities in smoking are widening over time in many countries. Low SES smokers may be more likely to smoke and less likely to quit because smoking is heavily concentrated in their social contexts. This study investigated whether low SES smokers (1) have more smoking friends, and (2) are more likely to gain and less likely to lose smoking friends over time. Correlates of having more smoking friends and gaining or losing smoking friends were also considered.

METHOD

Respondents included 6321 adult current smokers (at recruitment) from Wave 1 (2002) and Wave 2 (2003) of the International Tobacco Control Project (ITC) Four Country Survey, a nationally representative longitudinal cohort survey of smokers in Australia, Canada, UK, and US.

RESULTS

Low SES smokers reported more smoking friends than moderate and high SES smokers. Low SES smokers were also more likely to gain smoking friends over time compared with high SES smokers. Smokers who were male, younger, and lived with other smokers reported more smoking friends, and were also more likely to gain and less likely to lose smoking friends. Smoking behaviours, such as higher nicotine dependence were related to reporting more smoking friends, but not to losing or gain smoking friends.

CONCLUSIONS

Smoking is highly concentrated in the social networks of lower SES smokers and this concentration may be increasing over time. Cessation interventions should consider how the structure of low SES smokers' social networks affects quitting.

Smoking patterns and stimulus control in intermittent and daily smokers

Intermittent smokers (ITS) – who smoke less than daily – comprise an increasing proportion of adult smokers. Their smoking patterns challenge theoretical models of smoking motivation, which emphasize regular and frequent smoking to maintain nicotine levels and avoid withdrawal, but yet have gone largely unexamined. We characterized smoking patterns among 212 ITS (smoking 4–27 days per month) compared to 194 daily smokers (DS; smoking 5–30 cigarettes daily) who monitored situational antecedents of smoking using ecological momentary assessment. Subjects recorded each cigarette on an electronic diary, and situational variables were assessed in a random subset (n = 21,539 smoking episodes); parallel assessments were obtained by beeping subjects at random when they were not smoking (n = 26,930 non-smoking occasions). Compared to DS, ITS' smoking was more strongly associated with being away from home, being in a bar, drinking alcohol, socializing, being with friends and acquaintances, and when others were smoking. Mood had only modest effects in either group. DS' and ITS' smoking were substantially and equally suppressed by smoking restrictions, although ITS more often cited self-imposed restrictions. ITS' smoking was consistently more associated with environmental cues and contexts, especially those associated with positive or “indulgent” smoking situations. Stimulus control may be an important influence in maintaining smoking and making quitting difficult among ITS.

Women and Smoking: The Effect of Gender on the Epidemiology, Health Effects, and Cessation of Smoking

Smoking is still the leading cause of premature morbidity and mortality. This paper examines new research on gender differences and the epidemiology of smoking, smoking-related morbidity and mortality, and factors that affect smoking cessation. The rate of decline in the prevalence of smoking has been slowing, especially among adolescent girls. New research suggests that, compared with men, women may be more susceptible to smoking-related morbidity and mortality. Gender-related barriers to smoking cessation include weight gain, sex hormones, and mood. Furthermore, the sensory aspects of smoking may have more of an effect on smoking treatment for women than for men. We discuss new studies that examine smoking-cessation interventions that may be particularly beneficial for women, including exercise (as an adjunct intervention), very low nicotine content cigarettes, and a variety of pharmacotherapy. Further research is needed to identify and target the gender-specific needs of smokers.

Conceptualizing analyses of ecological momentary assessment data

Ecological momentary assessment (EMA) methods, which involve collection of real-time data in subjects' real-world environments, are particularly well suited to studying tobacco use. Analyzing EMA datasets can be challenging, as the datasets include a large and varied number of observations per subject and are relatively unstructured. This paper suggests that time is typically a key organizing principle in EMA data and that conceptualizing the data as a timeline of events, behaviors, and experiences can help define analytic approaches. EMA datasets lend themselves to answering a diverse array of research questions, and the research question must drive how data are arranged for analysis, and the kinds of statistical models that are applied. This is illustrated this with brief examples of diverse analyses applied to answer different questions from an EMA study of tobacco use and relapse.

Sex differences in cocaine/heroin users: drug-use triggers and craving in daily life

BACKGROUND

Studies of sex differences have shown that men and women with drug-use disorders differ in course and outcome and in cue-induced activation of putative brain "control network" areas. We evaluated sex differences in daily functioning and subjective events related to drug use with ecological momentary assessment (EMA).

METHODS

EMA data were collected from cocaine- and heroin-using outpatients (72 men; 42 women) in methadone maintenance in 2-5 randomly prompted (RP) entries per day and in participant-initiated entries for heroin or cocaine use or craving, for up to 25 weeks. Urine drug screens were conducted three times weekly. Data were analyzed via repeated-measures logistic regression, using sex as a predictor of responses.

RESULTS

In RP reports, women and men reported significantly different patterns of drug-cue exposure, with women significantly more likely to report having seen cocaine or been tempted to use in the past hour. Women also had higher craving after past-hour exposure to drug cues. In reports of drug use, women, compared to men, were more likely to report that they had used more cocaine than they had meant to, tended to feel guilty more often after drug use, and to have used despite trying not to use.

CONCLUSIONS

These findings provide real-time behavioral evidence that women respond differently than men to exposure to drug cues and to drug use, consistent with laboratory and brain-imaging findings. This information may be useful for development of sex-specific treatment strategies.

Smoking antecedents: separating between- and within-person effects of tobacco dependence in a multiwave ecological momentary assessment investigation of adolescent smoking

INTRODUCTION

Ecological momentary assessment (EMA) investigations have shown that the antecedents of smoking vary with individual differences in tobacco dependence. This has been interpreted as indicating that the transition to dependence is characterized by an erosion of external stimulus control over smoking. Rigorously testing this requires collecting multiple waves of EMA data, which permits separation of the influence of between- and within-person tobacco dependence variation in multilevel models.

METHODS

Adolescents (n = 313, 9th or 10th grade at baseline) participated in up to 4 waves of week-long EMA assessment over the course of 2 years as part of a larger longitudinal, observational study. At each wave, participants recorded contextual features and subjective states in response to prompted diary assessments and when smoking. They completed a youth-specific form of the Nicotine Dependence Syndrome Scale at each wave.

RESULTS

In cross-sectional multilevel analyses, smoking was less contingent on alcohol/drug use and was more common at home and in the morning for adolescents with higher levels of dependence. Multiwave analyses demonstrated that these effects were largely attributable to between-person variation in dependence, although parameter estimates for intraindividual dependence × antecedent effects tended to be in the predicted direction.

DISCUSSION

Findings provided partial support for the contention that the antecedents of smoking shift as an individual progresses to higher levels of dependence. Distinctive choices concerning smoking settings also appear to reflect between-person differences in propensity to dependence. More generally, the findings illustrate the value of using multilevel modeling and repeated EMA assessments to investigate the correlates of tobacco dependence at different levels of analysis.

Should all smokers use combination smoking cessation pharmacotherapy? Using novel analytic methods to detect differential treatment effects over 8 weeks of pharmacotherapy

INTRODUCTION

Combination pharmacotherapy for smoking cessation has been shown to be more effective than monotherapy in meta-analyses. We address the question of whether combination pharmacotherapy should be used routinely with smokers or if some types of smokers show little or no benefit from combination pharmacotherapy versus monotherapy.

METHODS

Two smoking cessation trials were conducted using the same assessments and medications (bupropion, nicotine lozenge, nicotine patch, bupropion + lozenge, and patch + lozenge). Participants were smokers presenting either to primary care clinics in southeastern Wisconsin for medical treatment (Effectiveness trial, N = 1,346) or volunteering for smoking cessation treatment at smoking cessation clinics in Madison and Milwaukee, WI (Efficacy trial, N = 1,504). For each trial, decision tree analyses identified variables predicting outcome from combination pharmacotherapy versus monotherapy at the end of treatment (smoking 8 weeks after the target quit day).

RESULTS

All smokers tended to benefit from combination pharmacotherapy except those low in nicotine dependence (longer latency to smoke in the morning as per item 1 of the Fagerström Test of Nicotine Dependence) who also lived with a spouse or partner who smoked.

CONCLUSIONS

Combination pharmacotherapy was generally more effective than monotherapy among smokers, but one group of smokers, those who were low in nicotine dependence and who lived with a smoking spouse, did not show greater benefit from using combination pharmacotherapy. Use of monotherapy with these smokers might be justified considering the expense and side effects of combination pharmacotherapy.