Transcranial Magnetic Stimulation for Long-Term Smoking Cessation: Preliminary Examination of Delay Discounting as a Therapeutic Target and the Effects of Intensity and Duration

Comparing neuromodulation targets to reduce cigarette craving and withdrawal: a randomized clinical trial

Cigarette smoking remains the leading preventable cause of death, emphasizing the need for new therapeutics, such as repetitive transcranial magnetic stimulation (TMS). We tested the hypothesis that TMS to three targets would reduce cigarette craving and withdrawal by modulating connectivity within and between three canonical networks in a randomized clinical trial (ClinicalTrials.gov: NCT03827265). Participants (N = 72; DSM-5 tobacco use disorder, ≥1 year of daily smoking) received one session of TMS to hubs of canonical resting-state networks: the dorsolateral prefrontal cortex (dlPFC), superior frontal gyrus (SFG), posterior parietal cortex (PPC), and area v5 (control). Self-reports (craving, withdrawal, and negative affect) and resting-state functional connectivity were measured before and after stimulation. SFG stimulation significantly reduced craving (95% CI, 0.0476-7.9559) and withdrawal (95% CI, 0.9225-8.1063) versus control, with larger effects in men (D = 0.59) than in women (D = 0.30). SFG stimulation did not change network connectivity, whereas dlPFC stimulation increased somatomotor, default mode, and dorsal attention network connectivity. No severe or unexpected treatment-related adverse events occurred. These findings suggest that SFG shows promise as a target for smoking-cessation treatment, especially for men. Further trials are warranted to confirm efficacy and develop imaging biomarkers for precision neuromodulation.

Repetitive transcranial magnetic stimulation reduces smoking cravings by decreasing cerebral blood flow in the dorsolateral prefrontal cortex

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive brain stimulation method that has been increasingly used to treat psychiatric disorders, including tobacco use disorder. However, the neural mechanisms underlying the effects of rTMS remain unclear. This study aimed to examine the effectiveness of rTMS in smoking cessation and to explore the underlying neural mechanism of the treatment effect. In Experiment 1, we recruited 60 participants who smoked cigarettes and 60 healthy controls and used their baseline cerebral blood flow (CBF) measured by arterial spin labelling perfusion to determine the group-level difference in CBF. In Experiment 2, we used the left dorsolateral prefrontal cortex (DLPFC) as the target for subsequent 5-day rTMS treatment at a frequency of 10 Hz with 2000 pulses to observe the impact of rTMS on CBF, Fagerström test for nicotine dependence scores and Tiffney questionnaire on smoking urges scores. In Experiment 3, we measured functional connectivity to monitor the functional changes induced by rTMS and assessed their associations with smoking cravings and nicotine dependence scores. In Experiment 1, participants who smoked cigarettes presented significantly higher CBF in the left DLPFC and bilateral anterior cingulate cortex than healthy controls. In Experiment 2, rTMS significantly decreased CBF in the DLPFC and reduced Fagerström test for nicotine dependence scores and Tiffney questionnaire on smoking urges scores. In Experiment 3, rTMS increased functional connectivity between the left DLPFC and the bilateral superior frontal gyrus, right DLPFC, bilateral precuneus and bilateral parahippocampus in participants, who smoked cigarettes. Regional CBF is a tool to identify tobacco use disorder-related regional brain markers and targets for reducing nicotine dependence and smoking cravings through rTMS. A neural mechanism of left DLPFC rTMS may involve a reduction in CBF in the target area and an increase in functional connectivity between the target area and the DLPFC-striatal pathways.

Evidence-based treatment approaches for adolescent electronic cigarette use

ABSTRACT

Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product by adolescents. This article describes the harmful effects of e-cigarette use in adolescents and how to evaluate for severity of nicotine dependence. It also provides an overview of treatment approaches, including behavioral interventions, contingency interventions, pharmacologic options, school-based programs, combination and emerging approaches, and transcranial magnetic stimulation.

Transcranial magnetic stimulation for the rehabilitation of patients with addiction: current status and future prospects

INTRODUCTION

Substance use disorders (SUDs) are severe conditions that remain extremely challenging to treat in clinical practice. With high rates of non-response to current treatment options and several SUDs with no approved interventions, novel therapies are needed. Repetitive transcranial magnetic stimulation (rTMS) can non-invasively modulate the neurocircuitry of brain-based disorders, and investigation into its therapeutic potential for SUDs is growing rapidly.

AREAS COVERED

In this review, we summarize the clinical research to date evaluating its safety and efficacy for various SUDs. We highlight the investigations comparing different stimulation parameters to present our current understanding on optimal stimulation parameters. Additionally, we cover key research avenues in the use of neuroimaging to guide treatment, cue-induction paradigms, and adjunctive or combination treatments that may optimize outcomes.

EXPERT OPINION

Evidence of rTMS as an effective treatment for certain SUDs has emerged and is preliminary for others. There are a growing number of studies showing benefit and meta-analyses suggesting that rTMS can significantly reduce substance craving and consumption. However, the optimal approach has not been determined, and there is a great deal of heterogeneity in rTMS protocols and mixed outcomes. Further research into strategies for enhancing precision will be crucial in moving the field forward.

Associations between delay discounting and unhealthy behaviors in substance use recovery

BACKGROUND

Research on delay discounting (DD) is mixed on whether DD is a domain-specific component related to specific behaviors or a domain-general process that cuts across various behaviors. A pivotal group to test the associations between DD and unhealthy behaviors is individuals in recovery from substance use disorders (SUD), as they are moving away from a disorder toward a healthier state.

METHODS

Individuals in SUD recovery (n = 317) completed the Temptation Scale, the Health Behaviors Questionnaire, and an Adjusting Delay Discounting Task. An exhaustive model space search was performed using linear regression to examine associations between DD with temptation, engagement in unhealthy behaviors, and the total number of unhealthy behaviors participants engage in. We also tested whether remission status is associated with the total number of unhealthy behaviors participants engage in.

RESULTS

Results revealed that DD was positively associated with poor eating (p<.001), physical inactivity (p=.003), financial irresponsibility (p<.001), risky behaviors (p<.001), lack of personal development goals (p<.001), lack of household savings (p=.004), and lack of health behaviors (p=.003). DD was also positively associated with the total number of unhealthy behaviors participants engage in (p<.001). Participants who were not in remission engaged in more unhealthy behaviors compared to those who were in remission (p<.001).

CONCLUSION

In a sample of individuals in recovery from SUD, DD is not domain-specific and undergirds engagement in several maladaptive health behaviors that can negatively impact recovery. Thus, DD can be a target for interventions aiming to reduce other maladaptive behaviors in SUD recovery.

A preliminary randomized controlled trial of repetitive transcranial magnetic stimulation applied to the left dorsolateral prefrontal cortex in treatment seeking participants with cannabis use disorder

BACKGROUND

Cannabis use disorder (CUD) is a common and consequential disorder. When applied to the dorsolateral prefrontal cortex (DLPFC), repetitive transcranial magnetic stimulation (rTMS) reduces craving across substance use disorders and may have therapeutic clinical effects when applied in serial-sessions. The present study sought to preliminarily determine whether serial-sessions of rTMS applied to the DLPFC had a therapeutic effect in CUD.

METHODS

This study was a two-site, phase-2, double-blind, randomized-controlled-trial. Seventy-two treatment-seeking participants (37.5% Women, mean age 30.2±9.9SD) with ≥moderate-CUD were randomized to active or sham rTMS (Beam-F3, 10Hz, 20-total-sessions, two-sessions-per-visit, two-visits-per-week, with cannabis cues) while undergoing a three-session motivational enhancement therapy intervention. The primary outcome was the change in craving between pre- and post- treatment (Marijuana Craving Questionnaire Short-Form-MCQ-SF). Secondary outcomes included the number of weeks of abstinence and the number of days-per-week of cannabis use during 4-weeks of follow-up.

RESULTS

There were no significant differences in craving between conditions. Participants who received active-rTMS reported numerically, but not significantly, more weeks of abstinence in the follow-up period than those who received sham-rTMS (15.5%-Active; 9.3%-Sham; rate ratio = 1.66 [95% CI: 0.84, 3.28]; p=0.14). Participants who received active-rTMS reported fewer days-per-week of cannabis use over the final two-weeks of the follow-up period than those receiving sham-rTMS (Active vs. Sham: -0.72; Z=-2.33, p=0.02).

CONCLUSIONS

This trial suggests rTMS is safe and feasible in individuals with CUD and may have a therapeutic effect on frequency of cannabis use, though further study is needed with additional rTMS-sessions and a longer follow-up period.

Managing substance use in patients receiving therapeutic repetitive transcranial magnetic stimulation: A scoping review

Repetitive Transcranial Magnetic Stimulation (rTMS) is an invaluable treatment option for neuropsychiatric disorders. Co-occurring recreational and nonmedical substance use can be common in those presenting for rTMS treatment, and it is unknown how it may affect the safety and efficacy of rTMS for the treatment of currently approved neuropsychiatric indications. This scoping review aimed to map the literature on humans receiving rTMS and had a history of any type of substance use. The search identified 274 articles providing information on inclusion/exclusion criteria, withdrawal criteria, safety protocols, type of rTMS and treatment parameters, adverse events and effect on primary outcomes that related to substance use. There are neurophysiological effects of substance use on cortical excitability, although the relevance to clinical rTMS practice is unknown. The current literature supports the safety and feasibility of delivering rTMS to those who have co-occurring neuropsychiatric disorder and substance use. However, specific details on how varying degrees of substance use alters the safety, efficacy, and mechanisms of rTMS remains poorly described.

A Preliminary Investigation Of Repetitive Transcranial Magnetic Stimulation Applied To The Left Dorsolateral Prefrontal Cortex In Treatment Seeking Participants With Cannabis Use Disorder

Background

Cannabis use disorder (CUD) is a common and consequential disorder. When applied to the dorsolateral prefrontal cortex (DLPFC), repetitive transcranial magnetic stimulation (rTMS) reduces craving across substance use disorders and may have a therapeutic clinical effect when applied in serial sessions. The present study sought to preliminarily determine whether serial sessions of rTMS applied to the DLPFC had a therapeutic effect in CUD.

Methods

This study was a two-site, phase-2, double-blind, randomized-controlled-trial. Seventy-two treatment-seeking participants (37.5% Women, mean age 30.2±9.9SD) with ≥moderate-CUD were randomized to active or sham rTMS (Beam-F3, 10Hz, 20-total-sessions, with cannabis cues) while undergoing a three-session motivational enhancement therapy intervention. The primary outcome was the change in craving between pre- and post-treatment (Marijuana Craving Questionnaire Short-Form-MCQ-SF). Secondary outcomes included the number of weeks of abstinence and the number of days-per-week of cannabis use during 4-weeks of follow-up.

Results

There were no significant differences in craving between conditions. Participants who received active rTMS reported numerically, but not significantly, more weeks of abstinence in the follow-up period than those who received sham rTMS (15.5%-Active; 9.3%-Sham; rate ratio = 1.66 [95% CI: 0.84, 3.28]; p=0.14). Participants who received active rTMS reported fewer days-per-week of cannabis use over the final two-weeks of the follow-up period (Active vs. Sham: -0.72; Z=-2.33, p=0.02).

Conclusions

This trial suggests rTMS is safe and feasible in individuals with CUD and may have a therapeutic effect on frequency of cannabis use, though further study is needed with additional rTMS-sessions and a longer follow-up period.

Repetitive transcranial magnetic stimulation for smoking cessation: Next steps for translation and implementation into clinical practice

Tobacco smoking is a significant determinant of preventable morbidity and mortality worldwide. It is now possible to modulate the activity of the neurocircuitry associated with nicotine dependence using repetitive Transcranial Magnetic Stimulation (rTMS), a non-invasive neurostimulation approach, which has recently demonstrated efficacy in clinical trials and received regulatory approval in the US and Canada. However there remains a paucity of replication studies and real-world patient effectiveness data as access to this intervention is extremely limited. There are a number of unique challenges related to the delivery of rTMS that need to be addressed prior to widespread adoption and implementation of this treatment modality for smoking cessation. In this paper, we review the accessibility, scientific, technological, economical, and social challenges that remain before this treatment can be translated into clinical practice. By addressing these remaining barriers and scientific challenges with rTMS for smoking cessation and delineating implementation strategies, we can greatly reduce the burden of tobacco-related disease worldwide.

Perceived research burden of a novel therapeutic intervention: A study of transcranial magnetic stimulation for smoking cessation

Background

Translating repetitive transcranial magnetic stimulation (rTMS) into evidence-based clinical applications relies on research volunteers with different perspectives on the burden of study participation. Additionally, clinical applications of rTMS require multiple visits over weeks or months, the impact of research burden is an important component for these studies and translation of these findings to clinical practice. High frequency rTMS has significant potential to be developed as an evidence-based treatment for smoking cessation, however, the optimal rTMS dosing strategies have yet to be determined. Participant burden is an important component of determining optimal dosing strategy for rTMS as a treatment for long-term smoking cessation.

Methods

In this double-blinded, sham-controlled, randomized design, the effects of treatment duration, intensity, and active/sham assignment of rTMS on research burden were examined.

Results

Overall level of perceived research burden was low. Experienced burden (M = 26.50) was significantly lower than anticipated burden (M = 34.12). Research burden did not vary by race or income.

Conclusions

Overall research burden was relatively low. Contrary to our hypotheses, we found little evidence of added significant burden for increasing the duration or intensity of rTMS, and we found little evidence for differences in research burden by race or income.

Clinical Trial Registration

identifier NCT03865472.