Affect, motivation, temptation, and drinking among alcohol-dependent outpatients trying to maintain abstinence: An Ecological Momentary Assessment study.

OBJECTIVES: Using Ecological Momentary Assessment we aimed to describe the time course of temptation episodes in alcohol-dependent outpatients in a real-life setting. We also examined whether affective and motivational variables were cross-sectionally and prospectively associated with temptation episodes. Additionally, we tested whether outpatients who drank against treatment goals (i.e., "lapsers") differed in craving, affect, and motivation from abstainers. METHODS: Participants were 43 alcohol-dependent outpatients (13 female). Using personal digital assistants (PDAs), patients were signaled to complete three random assessments per day for 4 weeks. They were also instructed to complete a temptation assessment whenever they experienced the temptation to drink alcohol. RESULTS: The number of temptation assessments declined over time and did not differ between lapsers and abstainers. Overall, craving was generally higher in lapsers (n = 14) than abstainers (n = 27). In lapsers, but not abstainers, abstinence motivation was lower at temptation assessments vs. random assessments. Across all patients, negative affect was prospectively associated with entry of temptation assessments later the same day. There were no significant effects for positive affect. CONCLUSIONS: In alcohol-dependent outpatients attempting to remain abstinent, negative affect is cross-sectionally associated with entry of temptation assessments. There is more evidence that negative affect precipitates temptations than vice versa. Professionals should be watchful of outpatients who report generally high levels of craving, and who report more negative affect and lower abstinence motivation, when tempted.

Associations between dispositional mindfulness, craving, and drinking in alcohol-dependent patients: An ecological momentary assessment study.

Hazardous alcohol use remains a significant global public health problem. A better understanding of relapse may assist the development of new interventions. Low levels of dispositional mindfulness may be a risk factor for craving and alcohol use, but few studies have examined these associations prospectively in an alcohol-dependent sample. In an ecological momentary assessment (EMA) study, Dutch alcohol dependent patients (N = 43) carried around a personal digital assistant for 4 weeks while trying to maintain abstinence. Participants completed assessments at random times 3 times per day, and when they felt a strong urge to drink or came to the brink of drinking without doing so. At each assessment, stress, negative affect, craving, recent drinking, and attentional or approach bias were assessed. Dispositional mindfulness was assessed at baseline with the Mindful Attention Awareness Scale (MAAS). More mindful individuals (higher MAAS scores) reported lower craving than less mindful individuals. There was no evidence that stress, negative affect, attentional bias, or approach bias mediated the association between MAAS and craving. However, there was evidence for an indirect path from MAAS to drinking such that higher mindfulness was associated with lower craving ratings that in turn were associated with less drinking. There was no evidence that MAAS significantly moderated associations between stress/negative affect/cognitive biases and craving, or between craving and drinking. In sum, more mindful recovering alcohol dependent patients reported lower craving ratings than less mindful patients, and this association appeared to be independent of stress/negative affect and cognitive biases. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Reprint of The effect of N-acetylcysteine and working memory training on cocaine use, craving and inhibition in regular cocaine users: correspondence of lab assessments and Ecological Momentary Assessment.

INTRODUCTION: Effective treatment for cocaine use disorder should dampen hypersensitive cue-induced motivational processes and/or strengthen executive control. Using a randomized, double-blind, placebo-controlled intervention, the primary aim of this study was to investigate the effect of N-Acetylcysteine (NAC) and working memory (WM)-training to reduce cocaine use and craving and to improve inhibition assessed in the laboratory and during Ecological Momentary Assessment (EMA). The second aim was to examine correspondence between laboratory and EMA data. METHODS: Twenty-four of 38 cocaine-using men completed a 25-day intervention with 2400mg/day NAC or placebo and WM-training as well as two lab-visits assessing cocaine use, craving and inhibition (Stop Signal task). Additionally, cocaine use, craving and cognition (Stroop task) were assessed using EMA during treatment, with 26 participants completing 819 assessments. RESULTS: Cocaine problems according to the Drug Use Disorder Identification Test (DUDIT) decreased more after NAC than after placebo, and the proportion of cocaine-positive urines at lab-visit 2 was lower in the NAC group. No NAC effects were found on craving. For cocaine use and craving, results from the lab data were generally similar to EMA results. NAC also showed some effects on cognitive control: improved inhibition assessed with the Stop Signal task in the lab, and decreased classic Stroop performance during EMA. There were no significant effects of number of completed WM-training sessions. CONCLUSIONS: Overall this study revealed mixed findings regarding the treatment of cocaine use disorders with NAC and WM-training. The effect of NAC on inhibition should be further investigated.

Pro-tobacco advertisement exposure among African American smokers: An ecological momentary assessment study.

INTRODUCTION: Many African Americans live in communities with a disproportionately high density of tobacco advertisements compared to Whites. Some research indicates that point-of-sale advertising is associated with impulse purchases of cigarettes and smoking. Ecological Momentary Assessment (EMA) can be used to examine associations between tobacco advertisement exposure and smoking variables in the natural environment. METHODS: Non-treatment seeking African American smokers were given a mobile device for 2weeks (N=56). They were prompted four times per day and responded to questions about recent exposure to tobacco advertisements. Participants were also asked to indicate the number of cigarettes smoked, and if they made any purchase, or an impulse purchase, since the last assessment. Linear mixed models (LMMs) analyzed between- and within-subject associations between exposure and outcomes. RESULTS: Participants reported seeing at least one advertisement on 33% of assessments. Of those assessments, they reported seeing menthol advertisements on 87% of assessments. Between-subject analyses revealed that participants who on average saw more advertisements were generally more likely to report purchasing cigarettes and to purchase cigarettes on impulse. Within-subject analyses revealed that when an individual participant reported seeing more advertisements than usual they were more likely to have reported purchasing cigarettes, making an impulse purchase and smoking more cigarettes during the same period, but not the subsequent time period. CONCLUSIONS: Many African American smokers are frequently exposed to pro-tobacco marketing. Advertisement exposure is cross-sectionally associated with impulse purchases and smoking. Future research should assess prospective associations in more detail.

The effect of N-acetylcysteine and working memory training on cocaine use, craving and inhibition in regular cocaine users: correspondence of lab assessments and Ecological Momentary Assessment.

INTRODUCTION: Effective treatment for cocaine use disorder should dampen hypersensitive cue-induced motivational processes and/or strengthen executive control. Using a randomized, double-blind, placebo-controlled intervention, the primary aim of this study was to investigate the effect of N-Acetylcysteine (NAC) and working memory (WM)-training to reduce cocaine use and craving and to improve inhibition assessed in the laboratory and during Ecological Momentary Assessment (EMA). The second aim was to examine correspondence between laboratory and EMA data. METHODS: Twenty-four of 38 cocaine-using men completed a 25-day intervention with 2400mg/day NAC or placebo and WM-training as well as two lab-visits assessing cocaine use, craving and inhibition (Stop Signal task). Additionally, cocaine use, craving and cognition (Stroop task) were assessed using EMA during treatment, with 26 participants completing 819 assessments. RESULTS: Cocaine problems according to the Drug Use Disorder Identification Test (DUDIT) decreased more after NAC than after placebo, and the proportion of cocaine-positive urines at lab-visit 2 was lower in the NAC group. No NAC effects were found on craving. For cocaine use and craving, results from the lab data were generally similar to EMA results. NAC also showed some effects on cognitive control: improved inhibition assessed with the Stop Signal task in the lab, and decreased classic Stroop performance during EMA. There were no significant effects of number of completed WM-training sessions. CONCLUSIONS: Overall this study revealed mixed findings regarding the treatment of cocaine use disorders with NAC and WM-training. The effect of NAC on inhibition should be further investigated.

Evaluating the influence of at-risk alcohol use on factors associated with smoking cessation: Combining laboratory and ecological momentary assessment.

OBJECTIVE: Most smokers want to quit but most cessation attempts end in failure. Alcohol consumption is associated with smoking behavior and relapse. We examined the associations between severity of drinking and psychological processes during a cessation attempt in the laboratory and during a quit attempt. METHODS: Smokers (N=209) enrolled in a smoking cessation study were followed from 2 weeks pre-quit through 4 weeks post-quit. Participants scoring 0-7 and 8-15 on the Alcohol Use Disorders Identification Test (AUDIT) were classified as low-risk and high-risk drinkers, respectively. Participants attended one pre-quit laboratory session before which they were required to abstain from smoking and another pre-quit session before which they smoked normally. Craving was assessed in the laboratory with the Questionnaire for Smoking Urges (QSU). A subsample of the participants also completed a 1-week ecological momentary assessment (EMA) study starting on the quit day. During EMA, craving for cigarettes was assessed, and attentional bias was assessed using a smoking Stroop task (n=119). RESULTS: High (vs. low) risk participants reported greater abstinence-induced increases in craving in the laboratory, and also exhibited greater attentional bias on the smoking Stroop task during EMA. CONCLUSIONS: High-risk drinkers exhibited a stronger increase in desire to smoke in abstinence and greater attentional bias to smoking cues early in a quit attempt, both of which may motivate continued smoking behaviors. High-risk drinkers may require more intensive or different smoking cessation interventions.

Effect of Brief Mindfulness Practice on Self-Reported Affect, Craving, and Smoking: A Pilot Randomized Controlled Trial Using Ecological Momentary Assessment.

INTRODUCTION: Despite efficacious pharmacological and behavioral treatments, most smokers attempt to quit without assistance and fail to quit. Mindfulness practice may be useful in smoking cessation. METHODS: This ecological momentary assessment (EMA) study was a pilot parallel group randomized controlled trial of a brief mindfulness practice (Brief-MP) intervention on self-reported smoking behavior delivered to smokers on a Personal Digital Assistant (PDA) in the field. Adult community smokers (N = 44) were randomly assigned to a Brief-MP (n = 24) or Control (sham meditation; n = 20) group. Participants were instructed to smoke as much or as little as they liked. Participants carried a PDA for 2 weeks and were instructed to initiate 20 minutes of meditation (or control) training on the PDA daily, completing an assessment of cognitive and affective processes immediately afterwards. Additionally, they completed assessments at random times up to four times per day. Primary outcome variables were negative affect, craving, and cigarettes smoked per day, all self-reported. RESULTS: Thirty-seven participants provided EMA data totaling 1874 assessments. Linear Mixed Model analyses on EMA data revealed that Brief-MP (vs. Control) reduced overall negative affect, F(1, 1798) = 13.8, P = .0002; reduced craving immediately post-meditation, (Group × Assessment Type interaction, F(2, 1796) = 12.3, P = .0001); and reduced cigarettes smoked per day over time (Group × Day interaction, F(1, 436) = 5.50, P = .01). CONCLUSIONS: Brief-MP administered in the field reduced negative affect, craving, and cigarette use, suggesting it may be a useful treatment.

Social support mediates the association of health literacy and depression among racially/ethnically diverse smokers with low socioeconomic status.

Nearly half of U.S. adults have health literacy (HL) difficulties, and lack the ability to effectively obtain, process, and understand health information. Poor HL is associated with depression, yet mechanisms of this relation are unclear. This study examined whether social support mediated the relation between HL and depressive symptoms in 200 low-socioeconomic status (SES), racially/ethnically diverse smokers enrolled in cessation treatment. Mediation analyses were conducted using bootstrapping and controlling for SES and nicotine dependence. In simple mediation models, social support [Interpersonal Support Evaluation List (ISEL) total, subscales (Appraisal, Belonging, Tangible)] mediated the effect of HL on depression, such that lower HL was associated with lower perceived support, which predicted higher depressive symptoms (ps < .05). A multiple mediation model, with ISEL subscales entered simultaneously as mediators, was significant (p < .05) but only the Belonging subscale demonstrating independent significance (p < .05). Thus, social support may be a critical factor underlying the HL-depression relationship in low-SES, racially/ethnically diverse smokers.

Lower health literacy predicts smoking relapse among racially/ethnically diverse smokers with low socioeconomic status.

BACKGROUND: Nearly half of U.S. adults have difficulties with health literacy (HL), which is defined as the ability to adequately obtain, process, and understand basic health information. Lower HL is associated with negative health behaviors and poor health outcomes. Racial/ethnic minorities and those with low socioeconomic status (SES) are disproportionately affected by poor HL. They also have higher smoking prevalence and more difficulty quitting smoking. Thus, lower HL may be uniquely associated with poorer cessation outcomes in this population. METHODS: This study investigated the association between HL and smoking cessation outcomes among 200, low-SES, racially/ethnically diverse smokers enrolled in smoking cessation treatment. Logistic regression analyses adjusted for demographics (i.e., age, gender, race/ethnicity, relationship status), SES-related characteristics (i.e., education, income), and nicotine dependence were conducted to investigate associations between HL and smoking relapse at the end of treatment (3 weeks post quit day). RESULTS: Results indicated that smokers with lower HL (score of < 64.5 on the Rapid Estimate of Adult Literacy in Medicine [REALM]) were significantly more likely than those with higher HL (score of ≥ 64.5 on the REALM) to relapse by the end of treatment, even after controlling for established predictors of cessation including demographics, SES, and nicotine dependence (OR = 3.26; 95% CI = 1.14, 9.26). CONCLUSIONS: Findings suggest that lower HL may serve as an independent risk factor for smoking relapse among low-SES, racially/ethnically diverse smokers enrolled in treatment. Future research is needed to investigate longitudinal relations between HL and cessation outcomes and potential mechanisms of this relationship.

Cognition and craving during smoking cessation: an ecological momentary assessment study.

INTRODUCTION: Some studies using ecological momentary assessment (EMA) have revealed an association between craving for cigarettes and relapse. It is therefore important to understand the correlates of craving during smoking cessation. Attentional bias to smoking cues is a potential correlate of craving, but it has not previously been assessed using EMA during smoking cessation. METHODS: Smokers enrolled in a research smoking cessation study were offered the opportunity to take part in an EMA study. Volunteers carried around a personal digital assistant (PDA) for the first week of their quit attempt. They completed up to 4 random assessments (RAs) per day as well as assessments when they experienced a temptation to smoke and when they relapsed. Craving for cigarettes was assessed with a single item (1-7 scale). Attentional bias was assessed with a smoking Stroop task (a reaction time task) at every other assessment, as was self-reported attention to cigarettes. RESULTS: Data were available from 119 participants. Across 882 assessments, participants exhibited a significant smoking Stroop effect. Linear mixed models revealed a significant between-subject association between craving and the smoking Stroop effect. Individuals with higher levels of craving exhibited greater attentional bias. The within-subject association was not significant. Similar results were obtained for the relationship between self-reported attention to cigarettes and attentional bias. CONCLUSIONS: Attentional bias can be assessed in the natural environment using EMA during smoking cessation, and attentional bias is a correlate of craving during the early stages of a quit attempt.

Associations between health literacy and established predictors of smoking cessation.

OBJECTIVES: We examined associations between health literacy and predictors of smoking cessation among 402 low-socioeconomic status (SES), racially/ethnically diverse smokers. METHODS: Data were collected as part of a larger study evaluating smoking health risk messages. We conducted multiple linear regression analyses to examine relations between health literacy and predictors of smoking cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking risk perceptions and knowledge, self-efficacy, intentions to quit or reduce smoking). RESULTS: Lower health literacy was associated with higher nicotine dependence, more positive and less negative smoking outcome expectancies, less knowledge about smoking health risks, and lower risk perceptions. Associations remained significant (P < .05) after controlling for demographics and SES-related factors. CONCLUSIONS: These results provide the first evidence that low health literacy may serve as a critical and independent risk factor for poor cessation outcomes among low-socioeconomic status, racially/ethnically diverse smokers. Research is needed to investigate potential mechanisms underlying this relationship.

Implicit and explicit drug-related cognitions during detoxification treatment are associated with drug relapse: an ecological momentary assessment study.

OBJECTIVE: Relapse is a major problem in drug addiction treatment. Both drug craving and drug-related cognitions (e.g., attentional bias and implicit attitudes to drugs) may contribute to relapse. Using ecological momentary assessments, we examined whether craving and cognitions assessed during drug detoxification treatment were associated with relapse. METHOD: Participants were 68 heroin-dependent inpatients undergoing clinical detoxification at an addiction treatment center. Participants carried around a personal digital assistant for 1 week. Participants completed up to 4 random assessments (RAs) per day. They also completed an assessment when they experienced a temptation to use drugs (TA). At each assessment, participants reported their craving and attitudes to drugs. Implicit cognitions were assessed with a drug Stroop task (attentional bias) and an Implicit Association Test (implicit attitudes). RESULTS: Individuals who relapsed during the study week exhibited a larger attentional bias and more positive implicit attitudes to drugs than did nonrelapsers at TAs (but not RAs). In addition, compared to nonrelapsers, relapsers reported higher levels of craving and more positive explicit attitudes to drugs at TAs than at RAs. Additional within-subject analyses revealed that attentional bias for drugs at TAs increased before relapse. CONCLUSIONS: Drug-related cognitive processes assessed with ecological momentary assessments were associated with relapse during drug detoxification. Real-time assessment of craving and cognitions may help to identify which individuals are at risk of relapse and when they are at risk of relapse.

A pilot study on using eye tracking to understand assessment of surgical outcomes from clinical photography.

Appearance changes resulting from breast cancer treatment impact the quality of life of breast cancer survivors, but current approaches to evaluating breast characteristics are very limited. It is challenging, even for experienced plastic surgeons, to describe how different aspects of breast morphology impact overall assessment of esthetics. Moreover, it is difficult to describe what they are looking for in a manner that facilitates quantification. The goal of this study is to assess the potential of using eye-tracking technology to understand how plastic surgeons assess breast morphology by recording their gaze path while they rate physical characteristics of the breasts, e.g., symmetry, based on clinical photographs. In this study, dwell time, transition frequency, dwell sequence conditional probabilities, and dwell sequence joint probabilities were analyzed across photographic poses and three observers. Dwell-time analysis showed that all three surgeons spent the majority of their time on the anterior-posterior (AP) views. Similarly, transition frequency analysis between regions showed that there were substantially more transitions between the breast regions in the AP view, relative to the number of transitions between other views. The results of both the conditional and joint probability analyses between the breast regions showed that the highest probabilities of transitions were observed between the breast regions in the AP view (APRB, APLB) followed by the oblique views and the lateral views to complete evaluation of breast surgical outcomes.

Administering the Implicit Association Test in an ecological momentary assessment study.

The Implicit Association Test (IAT) is widely used to assess automatic associations in memory. The feasibility of administering the test in an Ecological Momentary Assessment setting was examined with 15 smokers and 15 nonsmokers who carried a handheld computer for 1 wk. as they went about their daily lives. They completed the Implicit Association Test on the computer at random times 4 times a day and whenever they felt suddenly anxious. Overall, participants completed 80.4% of random assessments (M = 23.4 assessments). Nonsmokers initially exhibited a more negative IAT Effect than smokers. Over repeated testing, however, the IAT Effect of nonsmokers (but not smokers) became less negative, and the between-group difference disappeared. The data show that it is feasible to administer the Implicit Association Test in an Ecological Momentary Assessment setting, and that the IAT Effect can change with extensive testing.

Correlates of susceptibility to smoking among Mexican origin youth residing in Houston, Texas: a cross-sectional analysis.

BACKGROUND: Survey data suggest that in Texas Latino youth exhibit higher rates of susceptibility to smoking than youth from other ethnic groups. In this analysis we examined the relationship between susceptibility to smoking and well-known risk factors associated with smoking initiation among a cohort of 11 to 13 year old Mexican origin youth residing in Houston, Texas. METHODS: We analyzed cross-sectional survey data from 1,187 participants who reported they had never smoked, even a puff of a cigarette. The survey assessed peer and family social influence, school and neighborhood characteristics, level of family acculturation and socioeconomic status, and attitudes toward smoking. Bivariate associations, Student's t-tests, and logistic regression analysis were used to examine predictors of susceptibility. RESULTS: Overall, 22.1% of the never-smokers were susceptible to smoking. Boys were more likely to be susceptible than girls (25.6% vs. 18.9%), and susceptible children were slightly older than non-susceptible children (12.1 vs. 11.8 years). In addition, multivariate analyses revealed that positive expectations about smoking exerted the strongest influence on susceptibility status (odds ratio = 4.85). Multivariate analyses further revealed that compared to non-susceptible participants, susceptibles were more likely to report peer influences supportive of smoking, lower subjective social status and more detentions at school, more temptations to try smoking and to have a mother and a brother who smokes. CONCLUSION: Our findings suggest that interventions that target positive expectations about smoking may be useful in this population. Furthermore, because youth encounter smoking-initiation risk factors in different social environments, our results underscore the continued need for both family- and school-based primary prevention programs to adequately combat their influence. The results also can be used to inform the development of culturally sensitive programs for Mexican origin youth.

Evaluating the utility of administering a reaction time task in an ecological momentary assessment study.

RATIONALE: Cognitive processes underlying drug use have typically been assessed in laboratory settings. More detailed and ecologically valid data may be possible if assessments were conducted in an ecological momentary assessment (EMA) setting. OBJECTIVES: We evaluated the feasibility and utility of administering a reaction time task on a hand-held computer (personal digital assistant, PDA) in an EMA setting. MATERIALS AND METHODS: Twenty-two smokers and 22 non-smokers carried around the PDA for 1 week as they went about their daily lives. They were beeped at random times four times per day (random assessments, RAs). Participants were also instructed to press an "anxiety assessment" (AA) button on the PDA whenever they felt suddenly anxious. At each assessment (RA, AA), participants responded to items assessing subjective, pharmacological, and contextual variables, and subsequently completed a Stroop task (classic-Stroop, emotional-Stroop, or smoking-Stroop task). RESULTS: Participants responded to 81.2% of RAs, completed assessments in an average of 4.44 min, reported no interruptions on the majority of assessments (62.4%), and produced data with adequate reliability. Using generalized estimating equation (GEE) analyses, age was associated with the classic-Stroop effect, state anxiety was associated with the emotional-Stroop effect, and Fagerstrom Test for Nicotine Dependence scores were associated with the smoking-Stroop effect. CONCLUSIONS: The study provided evidence for the feasibility and utility of the approach.

Are variations in rates of attending cultural activities associated with population health in the United States?

BACKGROUND: Population studies conducted in Sweden have revealed an association between attendance at cultural activities and health. Using data from US residents, we examined whether the association could be observed in the US. METHODS: Participants in the current study included 1,244 individuals who participated in the 1998 General Social Survey. RESULTS: A significant association between cultural activities and self-reported health (SRH) was observed, even after controlling for age, gender, marital status, race, number of children, subjective social class, employment status, household income, and educational attainment. Specifically, the more cultural activities people reported attending, the better was their SRH. CONCLUSION: The data confirm that an association between cultural activity and health is present in a US sample. The data do not mean that the association is causal, but they suggest that further longitudinal research is warranted.