Alcohol and tobacco cessation in alcohol-dependent smokers: analysis of real-time reports.

Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary (ED) assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. ED data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior ED ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model.     

Dynamic influences on smoking relapse process

This article describes a program of research applying Ecological Momentary Assessment (EMA) methods to study relapse to cigarette smoking, with a particular focus on the role of negative affect (NA) and self-efficacy (SE). Day-to-day changes in mood and stress did not predict lapse risk, but more proximal changes in affect were associated with lapses: Many lapses were marked by intense NA and by NA increases in the preceding hours. Individual differences in baseline SE predicted lapse risk, but daily SE was relatively stable during abstinence and did not influence lapse risk. However, lapses resulted in immediate drops in SE, and day-to-day changes in postlapse SE predicted progression to relapse, even after accounting for concurrent smoking. SE showed momentary drops associated with NA, but only among smokers with low baseline SE. Individual differences in baseline SE were only expressed situationally under conditions of NA. The findings highlight the importance of dynamic changes in background conditions and in immediate states as important influences on lapses and relapse and also suggest the importance of considering person by situation interactions.     

Dynamic self-efficacy and outcome expectancies: prediction of smoking lapse and relapse

According to social learning models of drug relapse, decreases in abstinence self-efficacy (ASE) and increases in positive smoking outcome expectancies (POEs) should foreshadow lapses and relapse. In this study, the authors examined this hypothesis by using ecological momentary assessment data from 305 smokers who achieved initial abstinence from smoking and monitored their smoking and their ASE and POEs by using palmtop computers. Daily ASE and POEs predicted the occurrence of a 1st lapse on the following day. Following a lapse, variations in daily ASE predicted the onset of relapse, even after controlling for concurrent smoking. ASE and POEs generally neither mediated nor moderated each other's effects. These data emphasize the role of dynamic factors in the relapse process.     

Situational correlates of abstinence self-efficacy

Little is known about the situations that are associated with changes in self-efficacy during an attempt to quit smoking. In this study, 214 smokers used palmtop computers to record momentary self-efficacy ratings and situational context during a quit attempt. Higher urge to smoke and negative affect were associated with reduced self-efficacy. Although alcohol and coffee consumption are associated with heightened lapse risk, they were unrelated to abstinence self-efficacy. Individuals with low baseline self-efficacy generally reported lower self-efficacy across situations, but these differences were more pronounced under conditions of high urge and negative affect. These results suggest that self-efficacy may be reactive to affect-motivational states during a quit attempt. Whether these influences represent cognitive biases or objective risk assessments is not known.     

Smoking patterns and dependence: contrasting chippers and heavy smokers

The authors used ecological momentary assessment to contrast smoking patterns among chippers (CHs; n = 26)--smokers who smoke despite an apparent absence of tobacco dependence--with those seen in heavy smokers (HSs; n = 28). Smoking and nonsmoking settings (activity, mood, etc.) were assessed by means of electronic diary. CHs were not social smokers; like HSs, they smoked half their cigarettes while alone. When smoking, CHs' urge levels equaled those of HSs; between cigarettes, CHs had few urges, whereas HSs reported moderate urges. CHs' smoking was particularly associated with indulgent activities: relaxation, socializing, eating, and drinking alcohol. Outside of these indulgent settings, CHs' (but not HSs') smoking was associated with negative affect. In idiographic analyses, CHs' smoking was under much stronger stimulus control than was that of HSs. The authors propose that the disappearance of stimulus control over use is a characteristic of dependence.     

Relapse dynamics during smoking cessation: recurrent abstinence violation effects and lapse-relapse progression

Smoking cessation is a process that unfolds over time and is characterized by intermittent lapses. We used parametric recurrent event survival analyses to better understand the dynamic relationship between a set of Abstinence Violation Effect (AVE, Marlatt & Gordon, 1985) responses to lapsing and subsequent lapse-relapse progression. Participants were 203 smokers who achieved abstinence and responded to items assessing three core components of the AVE (internal attribution, abstinence self-efficacy and guilt) following a total of 1,001 lapse episodes in near real time. Neither self-blame, self-efficacy, nor guilt following participants' first lapse predicted relapse. Controlling for responses to their first lapse, responses to each additional lapse did prospectively predict lapse progression, such that drops in self-efficacy were associated with accelerated progression to a subsequent lapse (HR = 1.09, CI = 1.02-1.15), while increases in internal attributions of blame actually protected against lapsing (HR = 0.98, CI = 0.97-0.99). Treatment with nicotine patches slowed recurrent lapse progression (HR = 0.58, CI = 0.48-0.70), but this effect dissipated over multiple lapses, and was moderated by elevated ratings of postlapse guilt (HR = 1.08, CI = 1.01-1.18), which predicted accelerated progression within the active patch group, while protecting against lapse in the placebo group. Results highlight the dynamic nature of lapse responses during smoking cessation, indicating that self-efficacy predicts progression from one lapse to the next, while attributions of self-blame and guilt influenced progression in unexpected ways.     

Concurrent brief versus intensive smoking intervention during alcohol dependence treatment.

Alcohol dependent smokers (N=118) enrolled in an intensive outpatient substance abuse treatment program were randomized to a concurrent brief or intensive smoking cessation intervention. Brief treatment consisted of a 15-min counseling session with 5 min of follow-up. Intensive intervention consisted of three 1-hr counseling sessions plus 8 weeks of nicotine patch therapy. The cigarette abstinence rate, verified by breath carbon monoxide, was significantly higher for the intensive treatment group (27.5%) versus the rate for the brief treatment group (6.6%) at 1 month after the quit date but not at 6 months, when abstinence rates fell to 9.1% for the intensive treatment group and 2.1% for the brief treatment group. Smoking treatment assignment did not significantly impact alcohol outcomes. Although intensive smoking treatment was associated with higher rates of short-term tobacco abstinence, other, perhaps more intensive, smoking interventions are needed to produce lasting smoking cessation in alcohol dependent smokers.     

Drinking trajectories following an initial lapse.

Relapse following alcohol treatment is a major problem for individuals who are alcohol dependent, yet little is known about the course of drinking after the initial lapse. In the current study, discrete-time survival analysis and latent growth mixture modeling were used to evaluate the time to first lapse and the trajectories of postlapse drinking in a sample of 563 individuals who received community alcohol treatment. Results showed a decreasing risk of lapsing over time. After the initial lapse, 3 trajectory subgroups provided a parsimonious representation of the heterogeneity in postlapse drinking frequency and quantity, with the majority of individuals reporting light, infrequent drinking. Covariate analyses incorporating demographics, distal risk factors, time to first lapse, and coping behavior as predictors of time to lapse and postlapse drinking trajectories indicated that alcohol dependence and coping behavior were the strongest predictors of lapsing and postlapse drinking behavior.     

Concurrent drinking and smoking among college students: An event-level analysis

Cigarette smoking and drinking commonly co-occur among college students, a population that is at high risk for developing alcohol and nicotine use disorders. Several studies have been conducted that have examined predictors of drinking or smoking to gain a better understanding of the antecedents of engaging in these behaviors. Yet, few studies have examined specific factors that influence concurrent smoking and drinking in this population. The current study used data from a 21-day electronic diary-based study of college students (n=86) who engaged in concurrent drinking and smoking to examine event-level associations between alcohol use and cigarette smoking in the student's natural environment. We specifically focused on within-person analyses of contexts in which students reported smoking and drinking simultaneously in comparison to contexts in which students reporting drinking without smoking. Situational contexts included environmental setting, whether s/he was alone or with others, and changes in stress and urges to smoke before initiating drinking. Results indicated that students drank more while smoking and smoked three times as many cigarettes, on average, during drinking episodes. Being with others at a party or a bar was associated with increased odds of smoking while drinking. Likewise, increased stress since the prior assessment predicted a greater likelihood of smoking while drinking. Based on the findings from the present study, it is important for future prevention and intervention efforts to consider social settings and heightened stress among students as potential risk factors for engaging in concurrent drinking and smoking.     

Effects of depressed mood on drinking refusal self-efficacy: examining the specificity of drinking contexts

College students with elevated depressive symptoms are more likely to engage in risky drinking and experience alcohol-related negative consequences. Efforts to understand the association between depressed mood and alcohol use have begun to identify the role of cognitive-motivational processes. Drinking refusal self-efficacy is one such process that influences the decision to drink, but its relationship with depressed mood remains unclear. The current study sought to clarify the role of these processes using a depressed mood induction procedure in a sample of college student drinkers. Eighty-six students were randomized to a depressed or neutral mood induction and completed assessments of drinking refusal self-efficacy. Depressed mood significantly decreased self-efficacy in high-risk drinking contexts related to depression, whereas ratings of other high-risk contexts were unaffected. These findings suggest that the association between hazardous drinking and depressed mood may be due in part to the direct influence of mood state on one's self-efficacy to resist drinking in relevant contexts.     

Early cessation success or failure among women attempting to quit smoking: trajectories and volatility of urge and negative mood during the first postcessation week

Aversive symptoms of abstinence from nicotine have been posited to lead to smoking relapse and research on temporal patterns of abstinence symptoms confirms this assumption. However, little is known about the association of symptom trajectories early after quitting with postcessation smoking or about the differential effects of tonic (background) versus phasic (temptation-related) symptom trajectories on smoking status. The current study examined trajectories of urge and negative mood among 300 women using the nicotine patch during the first postcessation week. Ecological momentary assessments collected randomly and during temptation episodes were analyzed using hierarchical linear modeling yielding four individual trajectory parameters: intercept (initial symptom level), linear slope (direction and rate of change), quadratic coefficient (curvature), and volatility (scatter). Early lapsers, who lapsed during the first postcessation week, exhibited more severe tonic urge and phasic negative mood immediately after quitting, and more volatile tonic and phasic urge compared to abstainers. Late lapsers, who were abstinent during the first week but lapsed by 1 month, exhibited more severe tonic urge immediately after quitting compared to abstainers. These results demonstrate the importance of early postcessation urge and negative affect and highlight the value of examining both tonic and phasic effects of abstinence from nicotine.     

Effects of Depressed Mood on Drinking Refusal Self-Efficacy: Examining the Specificity of Drinking Contexts

College students with elevated depressive symptoms are more likely to engage in risky drinking and experience alcohol-related negative consequences. Efforts to understand the association between depressed mood and alcohol use have begun to identify the role of cognitive-motivational processes. Drinking refusal self-efficacy is one such process that influences the decision to drink, but its relationship with depressed mood remains unclear. The current study sought to clarify the role of these processes using a depressed mood induction procedure in a sample of college student drinkers. Eighty-six students were randomized to a depressed or neutral mood induction and completed assessments of drinking refusal self-efficacy. Depressed mood significantly decreased self-efficacy in high-risk drinking contexts related to depression, whereas ratings of other high-risk contexts were unaffected. These findings suggest that the association between hazardous drinking and depressed mood may be due in part to the direct influence of mood state on one's self-efficacy to resist drinking in relevant contexts.     

How does coping help people resist lapses during smoking cessation?

OBJECTIVES: To determine whether types of coping strategies have differential effects on preventing lapses and lowering urge levels and to investigate mechanisms by which coping strategies prevent lapses during smoking cessation. DESIGN: Sixty-one respondents performed ecological momentary assessment using palm-top computers and tape recorders to report their coping strategies and urge levels before and after temptations to smoke. Multilevel linear regression models were used to compare the effects of individual strategy types with the average strategy. MAIN OUTCOME MEASURES: Lapses versus resisted temptations and changes in urge levels. RESULTS: Number of strategies significantly predicted resisting smoking and change in urge levels. Compared with the effect of the average strategy, movement/exercise was marginally worse at preventing lapses, and food/drink was marginally related to higher postcoping urge levels. CONCLUSION: Although using multiple coping strategies helps people resist the urge to smoke, no particular coping strategy works better than any other. Coping strategies prevent lapses by reducing high urge levels during temptations.     

Naltrexone's effects on reactivity to alcohol cues among alcoholic men

The mechanisms of naltrexone's effects on urges to drink during abstinence are unclear. Naltrexone may suppress either urges to drink specifically or appetitive responses in general. The effects of naltrexone on cue reactivity to alcoholic and sweet nonalcoholic beverages were investigated. Alcohol-dependent men (N = 53) in treatment received naltrexone (50 mg) or placebo. Four hours later, they received baseline assessment, exposure to fruit juice, and exposure to their usual alcoholic beverage in 3-min trials. Naltrexone reduced urge to drink and self-reported attention to the alcohol cues, not at the initial exposure but after repeated exposures to alcohol cues. Naltrexone reduced negative affect across baseline and alcohol trials. No effects of naltrexone on responses to the nonalcoholic appetitive beverage cues were found, suggesting that general appetite suppression does not mediate the effects of naltrexone on urges.     

Negative mood,depressive symptoms,and major depression after smoking cessation treatment in smokers with a history of major depressive disorder

Negative mood, depressive symptoms, and major depressive episodes (MDEs) were examined in 179 smokers with a history of major depression in a trial comparing standard smoking cessation treatment to treatment incorporating cognitive-behavioral therapy for depression (CBT-D). Early lapses were associated with relatively large increases in negative mood on quit date. Mood improved in the 2 weeks after quit date among those returning to regular smoking but not among those smoking moderately. Continuous abstinence was associated with short- and long-term reductions in depressive symptoms. MDE incidence during follow-up was 15.3% and was not associated with abstinence. Unexpected was that CBT-D was associated with greater negative mood and depressive symptoms and increased MDE risk. Results suggest complex bidirectional associations between affect and smoking outcomes.     

Prolonged Exposure Therapy for PTSD among Individuals in a Residential Substance Use Treatment Program: A Case Series

Clients with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders present a unique challenge for clinicians in substance use treatment settings. Substance dependent individuals with PTSD tend to improve less during substance use treatment and relapse more quickly following abstinence attempts compared to those without PTSD. Recent scientific efforts have focused on understanding the potential benefit of providing PTSD treatment concurrent with substance use treatment. The current case study describes 4 individuals with PTSD in a residential substance use facility who received prolonged exposure therapy for treatment of PTSD, in addition to the substance use treatment. These individuals completed 9 bi-weekly 60-minute sessions of prolonged exposure, as well as in vivo and imaginal exposure homework between sessions. None of the clients met criteria for PTSD at the end of treatment, with these gains being maintained at 3- and 6-months post-treatment. Additionally, the clients did not relapse in response to undergoing exposure therapy. Implications for delivery of PTSD treatment in substance use treatment facilities are discussed.     

Nonnormality and divergence in posttreatment alcohol use: reexamining the Project MATCH data "another way."

Alcohol lapses are the modal outcome following treatment for alcohol use disorders, yet many alcohol researchers have encountered limited success in the prediction and prevention of relapse. One hypothesis is that lapses are unpredictable, but another possibility is the complexity of the relapse process is not captured by traditional statistical methods. Data from Project Matching Alcohol Treatments to Client Heterogeneity (Project MATCH), a multisite alcohol treatment study, were reanalyzed with 2 statistical methodologies: catastrophe and 2-part growth mixture modeling. Drawing on previous investigations of self-efficacy as a dynamic predictor of relapse, the current study revisits the self-efficacy matching hypothesis, which was not statistically supported in Project MATCH. Results from both the catastrophe and growth mixture analyses demonstrated a dynamic relationship between self-efficacy and drinking outcomes. The growth mixture analyses provided evidence in support of the original matching hypothesis: Individuals with lower self-efficacy who received cognitive behavior therapy drank far less frequently than did those with low self-efficacy who received motivational therapy. These results highlight the dynamical nature of the relapse process and the importance of the use of methodologies that accommodate this complexity when evaluating treatment outcomes.     

Changes in Hypothesized Mechanisms of Change Before and After Initiating Abstinence in Cognitive-Behavioral Therapy for Women With Alcohol Use Disorder

Abstinence self-efficacy, coping skills, and therapeutic alliance are hypothesized mechanisms of behavioral change (MOBCs) in cognitive-behavioral therapy (CBT) for alcohol use disorder (AUD). However, little is known about when these hypothesized MOBCs change during treatment or in relation to the initiation of abstinence from alcohol, which the current study investigated. Patient-reported abstinence self-efficacy, drinking-related coping skills, and therapeutic alliance were measured at every session throughout a 12-session clinical trial that previously showed equivalent drinking reductions in female-specific individual- and group-based CBT for AUD. Participants (N = 121 women) were classified into subgroups based on whether and when they first initiated 14 days of continuous abstinence from alcohol during treatment. Interrupted time-series analyses evaluated the magnitude and timing of change in MOBC variables in relation to the initiation of abstinence. All three MOBC measures showed gradual improvements throughout treatment (within-subjects d = 0.03 to 0.09 change per week). Participants who initiated abstinence during treatment experienced additional sudden improvements in abstinence self-efficacy (d = 0.47) and coping skills (d = 0.27), but not therapeutic alliance (d = -0.02), the same week they initiated abstinence. Participants who were already abstinent when treatment started maintained higher abstinence self-efficacy and coping skills, but not therapeutic alliance, throughout treatment compared to participants who never initiated abstinence. Initiating abstinence may help facilitate improvements in abstinence self-efficacy and drinking-related coping skills. Clinicians may help patients anticipate when and how much these variables are expected to improve during treatment and encourage initiation of abstinence to potentially help facilitate improvements in abstinence self-efficacy and coping skills.     

The subjective effects of alcohol-tobacco co-use: an ecological momentary assessment investigation

Alcohol and tobacco use covary at multiple levels of analysis, and co-use of the 2 substances may have profound health consequences. To characterize the motivationally relevant processes contributing to co-use, the current study used ecological momentary assessment (EMA) to examine the subjective consequences of naturally occurring simultaneous use of alcohol and tobacco. Current smokers who reported frequently drinking alcohol (N=259) used electronic diaries to monitor their daily experiences for 21 days. Participants responded to prompted assessments and also initiated recordings when they smoked a cigarette or completed the first drink in a drinking episode. Momentary reports of smoking and alcohol consumption were associated with one another, and these effects remained after adjustment for occasion- and person-level covariates. When participants consumed alcohol, they reported increased pleasure and decreased punishment from the last cigarette. Smoking was associated with small increases in pleasure from the last drink. Ratings of buzzed and dizzy were synergistically affected by co-use of alcohol and tobacco. Co-use was also followed by higher levels of craving for both alcohol and tobacco. Results point to the importance of reward and incentive processes in ongoing drug use and suggest that alcohol intensifies real-time reports of the motivational consequences of smoking more strongly than smoking affects corresponding appraisals of alcohol effects.     

Delineating potential mechanisms of implicit alcohol cognitions: drinking restraint, negative affect, and their relationship with approach alcohol associations

Problem drinkers may use alcohol to avoid negative mood states and may develop implicit cognitive associations between negative emotional states and reinforcing properties of drinking. It is paradoxical that attempts to control drinking, such as among those high in drinking restraint, may inadvertently increase desire to drink and subsequent alcohol consumption, and this may be exaggerated under times of emotional distress when urges to drink are high. We examined whether individuals who are high on drinking restraint would demonstrate stronger alcohol-related thoughts elicited by stimuli that represent the desire to use alcohol, in response to stronger versus weaker negative mood arousal. Seventy hazardous drinkers completed measurements of drinking restraint, alcohol consumption, and consequences of use. After being randomized to view negative or positive pictures sets, participants completed an Implicit Association Task (IAT) to test differences in the strength of the association between desire to approach or avoid alcohol or water cues, and then a measurement of subjective craving following the IAT. Regression analyses showed that trait restriction not temptation was positively related to IAT scores, after controlling for relevant covariates and explained 7% of the total variance. Trait temptation not IAT predicted subjective craving. Negative affect was unrelated to IAT scores, singly or in conjunction with measures of drinking restraint, contrary to predictions. In sum, implicit alcohol cognitions are related to attempts to restrict drinking not temptation to drink and are less strongly influenced by mood state.