An Examination of Cardiac Vagal Control Indices and Cognitive Stress Appraisal in Cigarette Smokers.

Identifying factors that influence how individuals who smoke cigarettes respond to stress is important as stress is a risk factor for smoking and its maintenance. This study examined the modulatory role of cardiac vagal control (CVC), a physiological correlate of self-regulation, on cognitive stress appraisal processes of adults who smoke. Sixty daily cigarette smokers were randomized to receive positive or negative feedback during a modified Trier Social Stress Test. Pre- and post-task stress appraisals were assessed and resting and reactivity CVC measures were computed. Moderated regression models assessed if the relation between feedback condition and post-task stress appraisal varied as a function of CVC. We hypothesized that participants receiving negative feedback would report greater post-task stress appraisal compared to participants receiving positive feedback, and the strength of the effect of both feedback groups would be greater at higher levels of CVC. All models showed significant main effects of feedback condition (b = - 0.42, p = 0.01; b = - 0.45, p = 0.01) on post-task stress appraisal: participants receiving negative feedback reported greater post-task stress appraisal. No significant main or interactive effects of CVC and feedback condition on post-task stress appraisal were observed. This study demonstrates that stress appraisals of daily cigarette smokers are sensitive to social feedback, but are not moderated by individual differences in CVC. Future investigations are needed to clarify whether this finding is explained by smoking-specific impairments in CVC as well as the distinct and interactive effects of physiological and psychological processes implicated in stress and smoking risk.

Cardiac Vagal Control Among Community Cigarette Smokers with Low to Moderate Depressive Symptoms.

Impairments in cardiac vagal control (CVC) have been independently linked to smoking status and depression and are implicated in self-regulatory processes that may exacerbate depressive symptoms and maintain smoking behavior. Yet, few studies have examined how depressive symptoms, even at low levels, influence CVC reactivity among individuals who smoke. Investigating these relationships may provide novel insights into how depressive symptoms exacerbate existing regulatory vulnerabilities among smokers. This study investigated how depression symptoms affect CVC reactivity as a function of changing situational demands among a community sample of 60 daily adult cigarette smokers. Participants completed a mildly demanding cognitive task while physiological data was recorded. Growth curve modeling was used to examine the main and interactive effects of self-reported depressive symptoms on CVC reactivity over the course of the task. We hypothesized that greater depressive symptoms would be associated with less CVC reactivity, characterized by smaller initial reductions in CVC values and a flatter slope over time. Participants were daily smokers with mild to moderate levels of depression. Final model results, where time was specified as linear and the slope was fixed, showed no significant main or interactive effects of time and depression symptoms on CVC reactivity. Findings suggest that at low to moderate levels, depressive symptom severity is not related to patterns of CVC reactivity among adults who smoke. This is the first study to examine this relationship in this population. Future investigations that examine patterns of CVC reactivity among smokers and non-smokers with more severe depression are needed.

The role of fear of COVID-19 in motivation to quit smoking and reductions in cigarette smoking: a preliminary investigation of at-risk cigarette smokers.

Preliminary data suggest that cigarette smokers could have an increased mortality risk from the novel coronavirus (SARS-CoV-2), and that certain factors (e.g., increased age, medical comorbidities) can also increase risk of poor coronavirus disease (COVID-19) outcomes. Between April 30th, 2020 and May 28th, 2020, we evaluated self-reported changes in recent smoking patterns and motivation to quit smoking among current daily cigarette smokers (N = 103) on Amazon Mechanical Turk. We also assessed the relationship of these outcomes to age, medical comorbidity status, and fear of COVID-19. Most participants (68.9%) reported smoking less frequently than usual in the last 28 days. Among daily smokers, increased fear of COVID-19 predicted increased motivation to quit smoking and actual smoking reductions (ps < .05). Endorsement of one or more medical comorbidities, but not increased age, predicted increased motivation to quit smoking (p < .05). These data suggest the potentially greater relevance of psychological factors (e.g., fear of COVID-19) over external risk factors (e.g., medical comorbidity, increased age) on motivation to quit smoking and actual reductions in smoking patterns, and may reflect that the pandemic is a suitable time for offering smoking cessation intervention.

A Pilot Randomized Clinical Trial of Brief Interventions to Encourage Quit Attempts in Smokers From Socioeconomic Disadvantage.

INTRODUCTION: Cigarette smoking disproportionately affects communities of low socioeconomic status where greater smoking prevalence and poorer cessation rates have been observed. Utilizing brief evidence-based interventions to increase cessation attempts may be an effective and easily disseminable means by which to mitigate undue burden in this population. AIMS AND METHODS: The current intervention randomized daily smokers (N = 57) recruited from a local community soup kitchen to receive either Brief (eg, 30 m) Motivational Interviewing, Nicotine Replacement Therapy (NRT) sampling, or a Referral-Only intervention. Approximately half of participants (50.9%) reported not completing high school and many reported either just (41.4%) or not (40.4%) meeting basic expenses. Follow-up was completed approximately 1-month postintervention. RESULTS: Nonsignificant group differences indicated that participants randomized to the NRT sampling condition were more likely to make a quit attempt (moderate effect size). Approximately 40% of the sample reported making a serious quit attempt at follow-up. Significant differences in cigarettes per day at follow-up, controlling for baseline, were observed, with participants in the Motivational Interviewing condition, only, reporting significant reductions. Participants randomized to the NRT condition were significantly more likely to report using NRT patch and lozenge at follow-up (large effect). There were no differences between groups with respect to seeking behavioral support. Finally, we found that subjective financial strain moderated the effect of condition on change in cigarette consumption where NRT sampling was more effective for participants reporting less financial strain. CONCLUSIONS: Findings provide initial evidence for personalizing brief interventions to promote quit attempts in low-income smokers. IMPLICATIONS: While most clinical research on tobacco use and dependence focuses on successful sustained abstinence, the current study is novel because it examined three brief interventions designed to increase the number of quit attempts made by a nontreatment-seeking group suffering from health disparities (ie, smokers from socioeconomic disadvantage). These data suggest that nontreatment-seeking smokers from socioeconomic disadvantage can be influenced by Brief MIs and these interventions should be used to motivate smokers from socioeconomic disadvantage to make a quit attempt. Future studies should examine combined MIs including pharmacological and behavioral interventions.

Distress Intolerance in Relation to Reliance on Cigarettes for Weight, Shape, and Appetite Control.

BACKGROUND: Distress intolerance, one's inability to withstand distressing emotional or physical states, is a transdiagnostic vulnerability implicated in affect-based health behaviors, including cigarette smoking and poor weight control. The current study evaluated associations between distress intolerance and the reliance on cigarettes for management of weight, appetite, or body dissatisfaction, which may pose a burden for cessation and increase risk of weight-related health problems. METHOD: Daily smokers (n = 577) completed an online survey assessing distress tolerance and reliance on cigarettes for weight and shape control with the four subscales of the Smoking and Weight Eating Episodes Test (SWEET). Four hierarchical regression models were constructed to test the association between distress intolerance and SWEET scores, accounting for the effect of relevant covarying factors. RESULTS: After adjusting for model covariates, distress intolerance was significantly incrementally associated with greater tendency to rely on cigarettes to suppress appetite (adjR2 = .040), prevent overeating (adjR2 = .034), cope with body dissatisfaction (adjR2 = .046), and cope with nicotine withdrawal-related appetite increases (adjR2 = .030). CONCLUSION: Distress intolerance may play an etiological role in maladaptive use of cigarettes to control appetite, weight, and body dissatisfaction among daily smokers, particularly those with weight- or shape-related concerns. Interventions aimed at increasing perceived ability to withstand distress could potentially reduce reliance on cigarettes for the aforementioned purposes.

Examining the Role of Emotion Regulation in the Bidirectional Relation between Physiological and Subjective Stress Response among Daily Cigarette Smokers.

Cigarette smoking is associated with autonomic dysregulation and altered stress responsivity. There exists a reciprocal relation between subjective and physiological stress reactivity and recovery in smokers. Emotion regulation may impact the extent to which these domains influence each other. The current study examined the moderating role of lack of emotional awareness, lack of emotional clarity, and nonacceptance of emotions, in the relation between heart rate reactivity to, and subjective recovery from, stress, and vice versa. To determine specificity of cross-domain findings, these relations were also examined within domain. Fifty-six daily smokers (46.4% female; M age = 29.33, SD = 11.92) participated in a biological challenge. Heart rate and subjective distress were assessed continuously before, during, and after the challenge. Individual growth curve models revealed that deficits in emotional clarity significantly moderated the effect of heart rate reactivity on subjective recovery. Lack of emotional awareness also moderated the association between subjective reactivity and heart rate recovery. Emotion regulation processes did not affect relations within the same domain, but altered the relation across domains.

Distress Intolerance and Smoking Topography in the Context of a Biological Challenge.

INTRODUCTION: Distress intolerance (DI), one's perceived or behavioral incapacity to withstand distress, is implicated in psychopathology and smoking. This study evaluated the effect of DI on smoking reinforcement in the context of a carbon dioxide (CO2) biological challenge. METHODS: Adult daily smokers (n = 90; 48.9% female) were randomized to receive a single inhalation/breath of 35% CO2-enriched air (n = 45) or compressed room air (n = 45). Perceived DI was assessed before the challenge. Smoking reinforcement was examined via average post-challenge puff volume across puffs and at the puff-to-puff level. RESULTS: Higher DI was associated with an increased average puff volume (b = -4.7, p = .031). CO2 produced decreased average puff volume compared with room air (b = -7.7, p = .018). There was a DI* condition interaction (ƒ2 = 0.02), such that CO2 decreased average puff volume compared with room air in smokers with higher DI (b = -13.9, t = -3.06, p = .003), but not lower DI. At the puff-to-puff level, there was a significant interaction between DI, condition, and cubic time (b = 0.0003, p =. 037). Specifically, room air produced large initial puff volumes that decreased from puff to puff over the cigarette for high- and low-DI smokers. CO2 produced persistent flat volumes from puff to puff over the cigarette for higher DI smokers, whereas CO2 produced puff volumes like that of room air in lower DI smokers. DISCUSSION: Findings suggest DI heightens smoking reinforcement generally, and in the context of intense cardiorespiratory distress, is associated with stable and persistent smoking. DI is a promising therapeutic target that, if addressed through psychological intervention, may improve cessation outcomes by decreasing smoking reinforcement. IMPLICATIONS: This study contributes to our understanding of the relationship between DI and smoking reinforcement, via examining these processes in response to acute cardiorespiratory distress. Specifically, we found that smokers who are less tolerant of distress, as opposed to those who are more tolerant, evince a decrease in average puff volume, and consistently low puff-to-puff volume, in response to a biological stressor. These findings suggest that smokers high in DI alter smoking behavior following acute cardiorespiratory distress, perhaps to reduce overstimulation, yet also persist in smoking in a manner that suggests an inability to achieve satiation.

Examining the Relation Between Physiological and Psychological Components of Stress Reactivity and Recovery in Cigarette Smokers.

Cigarette smokers exhibit reduced physiological stress reactivity, yet it is unclear whether blunted reactivity predicts differences in subjective recovery and vice versa. The study examined whether basal heart rate and heart rate reactivity were related to recovery in anxiety following stress, and conversely, whether initial self-reported anxiety and anxiety reactivity were related to heart rate recovery. Fifty-six smokers completed a 10-min baseline period, a 4-min stressor, and a 10-min recovery period during which heart rate and anxiety were continuously assessed. Results indicated significant linear (p < .01, d = 0.31) and quadratic (p = .02, d = 0.27) effects of baseline heart rate and reactivity (linear p < .01, d = 0.80; quadratic p < .01, d = 0.66) on recovery in anxiety and significant linear (p < .01, d = 0.88) and quadratic (p < .01, d = 0.74) effects of anxiety reactivity on heart rate recovery. These findings suggest that reduced reactivity in both heart rate and anxiety predicted slower recovery in the opposite domain. Findings offer initial evidence for psychophysiological integration in cigarette smokers.

The role of emotion regulation in the experience of menstrual symptoms and perceived control over anxiety-related events across the menstrual cycle.

Hormonal variation throughout the menstrual cycle is posited to impact various physical and mental health symptoms; however, this is not observed in all women and mechanisms are not well understood. Difficulty in emotion regulation may elucidate differences that women experience in physical and mental health functioning between menstrual phases. We examined the moderating role of difficulty in emotion regulation in the relation between menstrual phase and menstrual symptom severity and perceived control over anxiety-related events, in healthy, regularly menstruating women. The participants were 37 women (Mage = 26.5, SD = 9.6). A series of regression analyses were used to examine whether individual differences in emotion regulation difficulties moderate the relation between menstrual phase and our outcomes, severity of menstrual symptoms and perceived control over anxiety-related events, using a within-subjects design. The analyses revealed that difficulty in emotion regulation significantly moderated the relation between menstrual phase and perceived control over anxiety-related events (ß = -0.42, p < .05), but not menstrual symptom severity. Women who reported higher emotion regulation difficulty experienced greater differences in perceived control over anxiety-related events between menstrual phases. Specifically, women with lower difficulty in emotion regulation report greater increase in control over anxiety during the late luteal phase compared to women with higher emotion regulation difficulty. Difficulty in emotion regulation may play an important role in understanding differences in menstrual phase-associated impairments, thereby informing the development of targeted interventions for vulnerable women.

Examining associations between cognitive-affective vulnerability and HIV symptom severity, perceived barriers to treatment adherence, and viral load among HIV-positive adults.

BACKGROUND: Little research on symptom impairment and quality of life among HIV-positive (HIV+) individuals has attended to the potential role of cognitive-affective vulnerabilities. Emerging research indicates that emotion regulation (ER), anxiety sensitivity (AS), and distress tolerance (DT) are associated with a range of mental health outcomes and demonstrate meaningful relations to clinical outcomes in HIV+ individuals. PURPOSE: In this investigation, we sought to concurrently examine these factors in relation HIV symptom severity, barriers to medication adherence, and disease viral load. METHOD: Participants were 139 HIV+ individuals (34 female; age M = 48.2 years, SD = 8.1, 42% Black) receiving outpatient HIV care and prescribed at least one antiretroviral medication. We used hierarchical regression analyses to concurrently examine ER, AS, and DT in relation to severity of HIV symptoms, barriers to medication adherence, and disease viral load. RESULTS: After accounting for alcohol use problems, cannabis dependence, gender, and education, AS was significantly associated with HIV symptom severity (ß = .35, p < .01) whereas ER evidenced a trend relation (ß = .19, p = .07). ER (ß = .45, p < .01), but not AS or DT, was significantly related to barriers to medication adherence, above and beyond variance accounted for by covariates. Finally, ER evidenced a trend level relation to viral load (ß = .21, p = .07), above and beyond variance accounted for by cannabis use. CONCLUSION: Findings provide an extension of previous research, suggesting unique roles of cognitive-affective vulnerabilities in terms of HIV symptom severity, medication use barriers, and infection symptomatology, and inform the refinement of current treatments for HIV+ individuals so as to improve functioning.

Difficulties in emotion regulation and ad libitum smoking topography: A secondary analysis.

INTRODUCTION: Despite the well-known linkages between poor emotion regulation and subjective smoking motives, little is known about the role of emotion regulation in predicting smoking reinforcement behavior. This study examined the relation between difficulties in emotion regulation and puff velocity data, a behavioral index of smoking reinforcement, in adult daily cigarette smokers. METHOD: The current study was a secondary analysis of data collected from non-treatment seeking daily smokers (N = 124). Participants completed the Difficulties in Emotion Regulation Scale (DERS) followed by an ad libitum smoking period during which puff topography data was collected via a handheld puffing device. Puff velocity served as our puff topography index and was examined at the average and puff-to-puff level using regression and multi-level models, respectively. RESULTS: Regression analyses showed no significant association between DERS scores and average puff velocity. In contrast, multi-level modeling found a significant quadratic time × DERS effect at the puff-to-puff level, such that those with greater emotion regulation difficulties inhaled more quickly at the initiation of the cigarette, whereas those with lower emotion regulation difficulties evidenced consistent puffing over the course of the cigarette. DISCUSSION: Smokers with greater difficulties in emotion regulation appear to smoke in a way that maximizes delivery of nicotine, perhaps to self-regulate distress. One's style of puffing may reflect a possible behavioral marker of negative reinforcement smoking, especially in the context of emotional distress. IMPLICATIONS: This study was the first to explore the relationship between difficulties in emotion regulation and a behavioral measure of smoking reinforcement.

Evaluation of perseveration in relation to panic-relevant responding: an initial test.

BACKGROUND: Perseveration reflects the tendency to engage in a behavior even when it is no longer rewarding nor produces the expected consequences. METHOD: The current study explored whether (1) individuals endorsing a recent (past 2 years) history of nonclinical panic attacks would report greater levels of perseveration compared to individuals without such a history; (2) whether individuals endorsing higher levels of perseveration would evidence greater panic-relevant responding to a 4-minute 10% carbon dioxide-enriched air challenge. RESULTS: Results indicated that individuals with, compared to without, a positive panic attack history endorsed significantly greater levels of perseveration. Additionally, greater pre-challenge levels of perseveration significantly predicted greater panic attack symptom severity as well as self-reported anxiety; these significant effects were evident above and beyond the variance accounted for by sex, trait-level negative affectivity, panic attack status, and distress tolerance as well as shared variance with the related constructs of persistence and perfectionism. DISCUSSION: Together, the current findings provide initial, albeit preliminary, support for the utility of investigating perseveration in relation to models of panic psychopathology specifically, and offer a further empirical context for perseveration-psychopathology relations in general.

Examination of the indirect effect of childhood emotional trauma on internalizing symptoms through distress intolerance.

OBJECTIVES: Extant studies document a prospective link between early childhood trauma and internalizing symptoms, such as anxiety and depression. Less is known regarding specific cognitive-affective mechanisms. The current study sought to examine distress intolerance (DI) as a mechanism that may explain the relation between early childhood emotional abuse and internalizing symptoms. PARTICIPANTS AND METHODS: Participants (N = 230; 54.3% women; mean age = 19.72, SD = 2.28) completed multiple self-report indices of early childhood emotional abuse, DI, and internalizing symptom indices. Using structural equation modeling, a series of mediation models was run to examine the indirect effect of childhood emotional abuse on latent and specific internalizing symptom indices through a latent index of subjective DI. RESULTS: Childhood emotional abuse was significantly associated with internalizing symptoms through DI (effect size range = .083-.227, medium to large). CONCLUSIONS: The results provide preliminary evidence for DI as a mechanism of interest in the relation between early childhood emotional abuse and internalizing symptoms.

Trial-level bias score versus mean bias score: Comparison of the reliability and external validity using dot-probe task among daily smokers.

INTRODUCTION: Attentional bias (AB) is an individual difference risk factor that represents the extent to which cigarette cues capture one's attention. AB is typically indexed by mean bias score (MBS), theoretically assuming that AB is static. However, poor reliability of MBS has threatened valid interpretation of the results on AB. Based on observed trial-by-trial temporal fluctuation and variability of attentional allocation, trial-level bias score (TLBS) has been introduced as an alternative index with evidence of better psychometric properties in various populations, as compared to MBS. However, such evidence is limited among daily smokers. The current study aimed to replicate and extend extant findings in a sample of daily smokers by hypothesizing that TLBS, as compared to MBS, would demonstrate superior reliability and external validity. METHODS: Forty-eight daily smokers completed self-reports, ad-libitum smoking, and a dot-probe task three times, which was comprised of 36 pairs of pictorial stimuli of cigarette and neutral cues, yielding 144 total trials. RESULTS: The TLBS demonstrated superior internal (range intra class correlation [ICC] = 0.79-0.95) and test-retest reliability (range ICC = 0.64-0.88) compared to MBS (range ICC = 0.31-0.40 and 0.06-0.16, respectively). However, few significant relations between either the MBS or TLBS and measures of biobehavioral and self-report indices of smoking reinforcement were observed. CONCLUSIONS: The current findings demonstrate that TLBS, as compared to MBS, is a more reliable measure of AB among daily smokers, while evidence of its external validity is limited.

Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression.

OBJECTIVE: Respiratory abnormalities are a hallmark of anxiety symptomatology and may serve as clinically useful modifiers for alleviating anxiety symptoms. However, gold-standard anxiety treatments (e.g., cognitive-behavioral interventions) often do not directly address respiratory components despite their theoretical utility and clinical accessibility. This review examined the clinical effectiveness of respiratory interventions, interventions that directly target respiration abnormalities and processes, in treating trait anxiety symptoms. METHODS: The final analysis included 40 randomized controlled trials including at least one measure of trait anxiety, a respiratory-focused intervention group, and a non-respiratory control-group (active or inactive treatment). Overall effects of respiratory focused interventions were examined, as well as the effect of hypothesized moderators. RESULTS: Respiratory component interventions yielded significantly greater improvements (moderate to large effect) in anxiety symptoms than controls, with the stronger effects observed in comparison to inactive, rather than active, control conditions. Significant heterogeneity in findings suggests that variability in intervention design, population, and control comparison may obfuscate interpretation of findings. CONCLUSIONS: Evidence supports the clinical utility of respiratory interventions as either an independent anxiety treatment, or as an adjunct to other interventions. Clinical and research implications of findings along with recommendations for ongoing investigations in this domain are discussed.

Perceived physical health and heart-focused anxiety among daily adult cigarette smokers: associations with affect-relevant smoking motives and outcome expectancies.

The present investigation examined heart-focused anxiety and perceived physical health in terms of affect-relevant cigarette smoking motives and outcome expectancies. Participants were a community sample of 140 adult daily smokers (81 women, mean age = 29.60 years, SD = 11.98). In terms of smoking motives, both heart-focused anxiety and perceived physical health incrementally predicted smoking for negative affect reduction motives above and beyond relevant covariates (gender, weekly alcohol consumption, daily smoking rate). Yet heart-focused anxiety, but not perceived physical health, was incrementally predictive of habitual motives, relative to the same covariates. With regard to smoking outcome expectancies, heart-focused anxiety was incrementally predictive of negative reinforcement outcome expectancies, whereas perceived physical health was not. Alternatively, perceived physical health was incrementally predictive of negative personal consequence outcome expectancies, but heart-focused anxiety was not. Findings are discussed in relation to the role of perceived health vulnerabilities in clarifying affect-oriented smoking motives and expectancies.

Negative affectivity as a moderator of the association between smoking status and anxiety sensitivity, anxiety symptoms, and perceived health among young adults.

The present investigation evaluated the moderational role of negative affectivity in the relation between smoking status and panic-relevant symptoms in a young adult sample (n = 222; 123 females; mean age = 22.45 years, SD = 8.08). Consistent with the prediction, negative affectivity moderated the association of smoking status with anxious arousal symptoms, anxiety sensitivity, and perceived health. Specifically, greater negative affectivity was associated with higher levels of anxious arousal and anxiety sensitivity and lower levels of perceived health among smokers compared to nonsmokers. The effects were evident after controlling for the variance accounted for by alcohol use problems and gender. Findings are discussed with regard to the role of negative affectivity in the relation between smoking and panic-related processes.

Electronic cigarettes and nicotine harm-reduction.

Electronic nicotine delivery system (ENDs) use has increased in prevalence over the last decade, which has led to questions about their public health impact. In this article, we explore the emergent research on the relative health effects of using ENDs versus combustible cigarettes, whether ENDs can be utilized to promote nicotine cessation, and whether the advent of ENDs' may lead to an increase in nicotine use and dependence. Extant research on ENDs' acute health effects find them to be lesser than use of combustible cigarettes. ENDs do not appear to be efficacious as an immediate cessation aid, and may be a 'gateway' to adolescent nicotine use. However, in the absence of longitudinal research, a determination of ENDs as a nicotine harm-reduction approach is premature.

The Sequential Indirect Effect of Negative Urgency on Drinking Consequences Through Distress Intolerance and Drinking Motives: Initial Examination in College Students Reporting Past Month Alcohol Use.

Identification of cognitive and affective vulnerabilities among college drinkers may aid in developing focused interventions that promote a reduction in the prevalence of alcohol use. Negative urgency (NU) and distress intolerance (DI) evidence concurrent, unique, and synergistic relations with drinking motives and negative consequences of alcohol use. Utilizing a sequential multiple mediation framework to investigate a comprehensive model of these variables, we examined NU as a behavioral risk factor that potentiates the development of DI, thereby contributing to drinking motives that increase the risk of problematic use in young adults. A diverse sample of undergraduate students (N = 616; M age= 19.1, SD=1.4, range=18-25; 50.6% female; 60.6% Caucasian; recruited between September 2015 and Spring 2017) reporting past month alcohol use completed an online questionnaire battery. The results suggested that NU may contribute to negative alcohol use outcomes via its relation to DI and the motivation to drink in order to cope with negative emotional states and conform to social pressure. These findings suggest that NU may be a primary intervention target in young adults.

Theoretical implications and clinical support for heart rate variability biofeedback for substance use disorders.

Heart rate variability (HRV) biofeedback is an accessible, cost-effective intervention that has demonstrated clinical value for numerous physical and mental health conditions; however, research on HRV biofeedback in substance use disorders (SUD) is in its nascence. We argue that HRV biofeedback may be particularly beneficial as an adjunct treatment for SUD by targeting bodily systems that are known to be disrupted by chronic substance use and are not historically the focus of psychosocial or pharmacological SUD treatment approaches. In addition to advocating for HRV biofeedback applications in SUD, we identify several gaps within the existing experimental literature, and propose new studies that could accelerate understanding of how and for whom HRV biofeedback is most likely to promote positive behavior change.