Rationale

Pathological gambling (PG) has recently been considered as a “behavioral” or non-substance addiction. A comparison of characteristics of PG and substance use disorders (SUDs) has clinical ramifications and could help advance future research on these conditions. Specific relationships with impulsivity and compulsivity may be central to understanding PG and SUDs.

Objectives

To compare and contrast research findings in PG and SUDs pertaining to neurocogntive tasks, brain function and neurochemistry, with a focus on impulsivity and compulsivity.

Results

Multiple similarities were found between PG and SUDs, including poor performance on neurocognitive tasks, specifically with respect to impulsive choice and response tendencies and compulsive features (e.g., response perseveration and action with diminished relationship to goals or reward). Findings suggest dysfunction involving similar brain regions, including the ventromedial prefrontal cortex (PFC) and striatum and similar neurotransmitter systems, including dopaminergic and serotonergic. Unique features exist which may in part reflect influences of acute or chronic exposures to specific substances.

Conclusions

Both similarities and differences exist between PG and SUDs. Understanding these similarities more precisely may facilitate treatment development across addictions, whereas understanding differences may provide insight into treatment development for specific disorders. Individual differences in features of impulsivity and compulsivity may represent important endophenotypic targets for prevention and treatment strategies.

Background

Adolescent and adult samples have shown that DSM-IV abuse and dependence criteria lie on a continuum of alcohol problem severity, but information on criteria functioning in college students is lacking. Prior factor analyses in a college sample (Beseler et al., 2010) indicated that a two-factor solution fit the data better than a single-factor solution after a binge drinking criterion was included. The second dimension may indicate a clustering of criteria related to excessive alcohol use in this college sample.

Methods

The present study was an analysis of data from an anonymous, online survey of undergraduates (N = 361) that included items pertaining to the DSM-IV alcohol use disorder (AUD) diagnostic criteria and binge drinking. Latent class analysis (LCA) was used to determine whether the criteria best fit a categorical model, with and without a binge drinking criterion.

Results

In a LCA including the AUD criteria only, a 3-class solution was the best fit. Binge drinking worsened the fit of the models. The largest class (class 1, n = 217) primarily endorsed tolerance (18.4%); none were alcohol dependent. The middle class (class 2, n = 114) endorsed primarily tolerance (81.6%) and drinking more than intended (74.6%); 34.2% met criteria for dependence. The smallest class (class 3, n = 30) endorsed all criteria with high probabilities (30% to 100%); all met criteria for dependence. Alcohol consumption patterns did not differ significantly between classes 2 and 3. Class 3 was characterized by higher levels on several variables thought to predict risk of alcohol-related problems (e.g., enhancement motives for drinking, impulsivity and aggression).

Conclusions

Two classes of heavy drinking college students were identified, one of which appeared to be at higher risk than the other. The highest risk group may be less likely to “mature out” of high-risk drinking after college.

Rationale

Attempts to simultaneously control food intake and smoking may lead to smoking cessation failure. We sought to model this relationship using a human laboratory paradigm of smoking lapse behavior.

Objectives

We examined the combined effect of food and nicotine deprivation, compared to nicotine deprivation alone, on the ability to resist smoking and on subsequent ad libitum smoking.

Methods

In a between-subjects design, daily smokers (N = 30) were all deprived of nicotine for 18 hours and were either food deprived (12 hrs) or not during a laboratory session. Following exposure to individualized food cues, participants had the option of initiating tobacco self-administration or delaying up to 50 minutes in exchange for monetary reinforcement. Subsequently, the tobacco self-administration period consisted of one-hour in which participants could choose to smoke or receive monetary reinforcement for cigarettes not smoked.

Results

Smokers who had been deprived of food and nicotine smoked their first cigarette sooner and were more likely to smoke at some point during the laboratory session, compared to those who were only nicotine deprived. Those who were food and nicotine deprived smoked slightly more cigarettes than those who were nicotine deprived only, although this difference was not statistically significant. There were no sex differences in outcomes. Hunger and food craving ratings while trying to resist smoking were greater in the food + nicotine deprived group. Tobacco craving was predictive of outcome in both conditions.

Conclusions

These findings support the hypothesis that food deprivation can undermine a smoker’s ability to resist smoking.

Introduction:

Given the prevalence of alcohol use among adolescents and its negative consequences, it is important to learn more about correlates of alcohol-related problems in this population. Cigarette smoking appears to be associated with alcohol-related problems in adolescents. The purpose of this study was to assess cigarettes smoked per day and nicotine dependence (ND) severity as predictors of alcohol-related problems in cross-sectional models, using data from a smoking cessation clinical trial for adolescents.

Method:

Data obtained at intake were used to assess smoking-related variables as cross-sectional predictors of alcohol-related problems in models along with drinks per week and key demographics, using hierarchical multiple regression.

Results:

ND severity, as measured using the modified Fagerström Tolerance Questionnaire, significantly predicted alcohol-related problems, both when this score included and did not include an item concerning cigarettes smoked per day. A separate continuous item capturing cigarettes per day did not predict alcohol-related problems.

Discussion:

ND severity predicted alcohol-related problems in cross-sectional regression models, holding constant alcohol consumption and key demographics. This suggests that ND severity may be a clinical indicator of alcohol-related problems among adolescent smokers. To our knowledge, this is the first analysis of associations between smoking and alcohol involvement in a sample of adolescent smokers participating in a clinical trial.

Trait disinhibition is associated with problem drinking and alcohol drinking itself can bring about a state of disinhibition. It is unclear however, if expectancies of alcohol-induced disinhibition are unique predictors of problem drinking. Impaired control (i.e., difficulty in limiting alcohol consumption) may be related to disinhibition expectancies in that both involve issues of control related to alcohol use. Data from a prospective survey of undergraduates assessed during freshman (N = 337) and senior year (N = 201) were analyzed to determine whether subscales of the Drinking-Induced Disinhibition Scale and the Impaired Control Scale predicted unique variance in heavy episodic drinking and alcohol-related problems. In Time 1 cross-sectional models, dysphoric disinhibition expectancies predicted alcohol-related problems and impaired control predicted both alcohol-related problems and heavy episodic drinking. In prospective models, Time 1 impaired control predicted Time 2 alcohol-related problems and Time 1 euphoric/social disinhibition expectancies predicted Time 2 heavy episodic drinking. These findings suggest that expectancies of alcohol-induced disinhibition and impaired control predict unique variance in problem drinking cross-sectionally and prospectively and that these phenomena should be targeted in early intervention efforts.

Tiffany’s (1990) cognitive processing model postulates that craving will only occur when access to alcohol is blocked. To test a hypothesis based on this model, we analyzed data from a naturalistic laboratory alcohol challenge study involving moderate-to-heavy drinking young adults (N = 174) with a focus on the placebo beverage condition of this study. Our hypothesis was that self-reports of “wanting more alcohol” (i.e., craving) in the lab, following placebo, would predict subsequent ad libitum consumption because placebo administration would constitute partial blocking of access to alcohol. We also tested the possibility that craving might mediate associations between personality traits and ad libitum consumption. Both trait disinhibition and reports of craving following the placebo beverage significantly predicted ad libitum consumption. Further, craving partially mediated the association between trait disinhibition and ad libitum consumption. Potential implications of these findings are discussed.

SUMMARY

Impulse control disorders (ICDs), specifically those related to excessive gambling, eating, sex and shopping, have been observed in a subset of people with Parkinson's disease (PD). Although some initial case reports claimed that dopamine replacement therapies, particularly dopamine agonists, cause ICDs, more recent, larger and better controlled studies indicate a more complicated picture. While dopamine replacement therapy use is related to ICDs, other vulnerabilities, some related to PD and/or its treatment directly and others seemingly unrelated to PD, have also been associated with ICDs in PD. This suggests a complex etiology with multiple contributing factors. As ICDs occur in a sizable minority of PD patients and can be associated with significant distress and impairment, further investigation is needed to identify factors that can predict who may be more likely to develop ICDs. Clinical implications are discussed and topics for future research are offered.

Heavy drinking young adults often have limited motivation to change their drinking behavior. Adding pharmacotherapy to brief counseling is a novel approach to treating this population. A small open-label pilot study was conducted to assess the feasibility of offering eight weeks of daily and targeted (i.e., taken as needed in anticipation of drinking) naltrexone with BASICS (brief motivational) counseling to heavy drinking young adults; to assess the tolerability of the medication in this population and to obtain preliminary efficacy data. The sample (N = 14) showed strong adherence to study appointments and medication taking, supporting the feasibility of this approach. Overall, the medication was well-tolerated. Significant reductions from baseline were observed in drinks per drinking day and in percent heavy drinking days and these gains were maintained one month after treatment ended. A significant decrease in alcohol-related consequences was also observed. Findings from this small pilot study suggest that naltrexone in combination with BASICS represents a promising strategy to reduce heavy drinking among young adults.

Aims

Impaired control, one of the hallmarks of addiction, is also one of the earliest dependence symptoms to develop. Thus impaired control is particularly relevant to undergraduates and other young adults with relatively brief drinking histories. The main goal of this study was to determine whether impaired control predicted heavy episodic drinking and alcohol-related problems cross-sectionally in an undergraduate sample after controlling for gender, family history of alcohol and drug problems and several other established predictor variables from the undergraduate alcohol literature.

Methods

A sample of first-year undergraduates (N = 312) completed Part 2 of the Impaired Control Scale (ICS; Heather et al., 1993) and other measures related to alcohol use as part of a larger study on problem drinking in undergraduates.

Results

Scores on Part 2 of the ICS predicted heavy episodic drinking and alcohol-related problems cross-sectionally even after controlling for all other predictor variables. Notably, impaired control was a stronger predictor of alcohol-related problems than overall weekly alcohol consumption. Part 2 of the ICS was found to be a reliable and valid measure for use with undergraduates.

Conclusions

These findings support the notion that impaired control is one of the earliest dependence symptoms to develop. The ICS is an effective tool for identifying young adults at risk for problem drinking.

The opiate antagonist naltrexone has demonstrated efficacy in the treatment of alcohol dependence and as a component of treatment to reduce heavy drinking. At present, there are no published dose-ranging clinical trials of the oral preparation for treatment of problem drinking. The present study evaluated the effects of naltrexone on alcohol use among the subset of hazardous drinkers (N = 102) who participated in a placebo-controlled, dose-ranging trial of oral naltrexone (25 mg, 50 mg and 100 mg doses) combined with open-label transdermal nicotine patch for enhancing smoking cessation. On the primary outcome—no hazardous drinking (drinking that exceeded weekly or daily limits) during treatment—25 mg and 50 mg naltrexone were superior to placebo (each p < 0.05). These findings remained after controlling for baseline predictors or smoking abstinence during treatment. Time to remission of hazardous drinking was examined as a secondary outcome with definitions of hazardous drinking based on weekly limits, daily limits and the combination of weekly and daily limits and the results were consistent with the primary findings. In conclusion, the findings suggest that naltrexone can reduce the risk of hazardous drinking in smokers who are not seeking or receiving alcohol treatment, providing strong evidence for the pharmacological effects of naltrexone on drinking. This effect appears to favor lower doses that may be better tolerated and less expensive than the higher 100 mg dose. Given its efficacy and favorable side effect profile, the 25 mg dose should be considered for future studies of combination therapy.

There is only modest overlap in the most common alcohol consumption phenotypes measured in animal studies and those typically studied in humans. To address this issue, we identified a number of alcohol consumption phenotypes of importance to the field that have potential for consilience between human and animal models. These phenotypes can be broken down into three categories: 1) abstinence/the decision to drink or abstain; 2) the actual amount of alcohol consumed and 3) heavy drinking. A number of suggestions for human and animal researchers are made in order to address these phenotypes and enhance consilience. Laboratory studies of the decision to drink or abstain are needed in both human and animal research. In human laboratory studies, heavy or binge drinking that meets cut-offs used in epidemiological and clinical trials should be reported. Greater attention to patterns of drinking over time is needed in both animal and human studies. Individual differences pertaining to all consumption phenotypes should be addressed in animal research. Lastly, improved biomarkers need to be developed in future research for use with both humans and animals. Greater precision in estimating blood alcohol levels in the field together with consistent measurement of breath/blood alcohol levels in human laboratory and animal studies provides one means of achieving greater consilience of alcohol consumption phenotypes.

There are well-established links between impulsivity and alcohol use in humans and other model organisms; however, the etiological nature of these associations remains unclear. This is likely due, in part, to the heterogeneous nature of the construct of impulsivity. Many different measures of impulsivity have been employed in human studies, using both questionnaire and laboratory-based tasks. Animal studies also use multiple tasks to assess the construct of impulsivity. In both human and animal studies, different measures of impulsivity often show little correlation and are differentially related to outcome, suggesting that the impulsivity construct may actually consist of a number of more homogeneous (and potentially more meaningful) subfacets. Here, we provide an overview of the different measures of impulsivity used across human and animal studies, evidence that the construct of impulsivity may be better studied in the context of more meaningful subfacets, and recommendations for how research in this direction may provide for better consilience between human and animal studies of the connection between impulsivity and alcohol use.

This study assesses the impact of the 1993 NIH Revitalization Act on the inclusion and subgroup analysis of women and minorities in trials of FDA-approved smoking cessation pharmacotherapy. Female representation, while commensurate with population levels, declined significantly for trials that began recruitment after 1993 (M = 47.2% vs. M=53.9%) and fewer than half reported analyses by gender. Minorities continued to be under-represented in later trials, however, significant improvement in representation (M=16.1% vs. M=10%) and analysis by race occurred. Industry sponsored studies had lower minority representation than NIH funded studies. Recommendations are offered to improve subgroup analyses and minority inclusion.

Disinhibition and addictive behaviors are related and carry moral implications. Both typically involve diminished consideration of negative consequences, which may result in harm to oneself or others. Disinhibition may occur on state and trait levels, and addictive substances may elicit disinhibitory states, particularly when intoxication is reached. Data suggest that trait disinhibition and addictions may be conceptualized as involving misdirected motivation with underlying biological bases including genetic factors, alterations in neurotransmitter systems and differences in regional brain function. The influences of intoxication on the brain share similarities with cognitive impairments in individuals with chronic substance abuse and those with trait disinhibition related to frontal lobe injuries. These findings raise questions about volitional impairment and morality. Although impaired volition related to disinhibition and addictive behaviors has been studied from multiple perspectives, additional research is needed to further characterize mechanisms of impairment. Such findings may have important implications in multiple legal and psychiatric domains.

Little is known about the impact of alcohol involvement on smoking cessation relapse or possible mechanisms for these associations. We addressed these issues using data from a randomized clinical trial of 2 types of framed messages (gain vs. loss) in conjunction with open label sustained-release (SR) bupropion (Toll et al., 2007) (N = 249). Participants were categorized according to whether or not they were diagnosed with a lifetime alcohol use disorder (AUD; i.e., current or past alcohol abuse or past alcohol dependence) and according to 3 levels of alcohol use: abstinence, moderate or hazardous use. Alcohol use categories were established for drinking at baseline, during the 6-week treatment period and through 12 weeks post-quit. There were few significant differences by baseline alcohol use level or AUD history for a series of predictors of smoking cessation failure (e.g., depressive symptoms). During treatment and follow-up, the probability of any smoking on heavy drinking days was significantly higher than the probability of smoking on moderate drinking or abstinent days. AUD history did not predict smoking cessation relapse in any analysis, nor were any alcohol use × AUD history interactions significant. Moderate alcohol users and to a lesser extent, abstainers from alcohol at baseline were less likely than hazardous drinkers to have relapsed at 12 weeks post-quit. Based on these findings, it appears that risk of any smoking and of relapse was associated primarily with heavy drinking days and a hazardous pattern of use respectively, rather than with moderate drinking.

Accruing evidence of an association between drinking and smoking relapse suggests that it is important to measure alcohol use in smoking cessation studies. However, most studies do not do so, often because of the extra time burden required for these assessments. Data from participants (N = 634) in two smoking cessation clinical trials were used to examine the relationship between short and longer periods of monitoring for a number of Timeline Followback (TLFB) drinking metrics at baseline and during treatment. High intercorrelations were found between short (7 & 14 days) and longer (30 & 60 days) time windows for baseline drinking data. Intercorrelations between short (last 7 days of treatment) and longer (entire treatment period) time windows of drinking data during the smoking cessation treatment period were also mostly in the high range. Although total abstinence was significantly overestimated with shorter time windows, for those who were misclassified, percentage of days abstinent was high and percentage of heavy drinking days and number of drinks per drinking day were low during the longer period. Thus, a brief estimate of alcohol use over 7 days at baseline is likely to provide a representative assessment of percentage of days abstinent, percentage of heavy drinking days, and number of drinks per drinking day. To estimate abstinence at baseline and during treatment, however, a more comprehensive period of monitoring may be required.

While the U. S. Food and Drug Administration has approved several medications for the treatment of alcohol-related problems, their use has not gained wide acceptance in the United States. Typically, patients with alcohol use disorders are only referred to psychosocial support (e.g., Alcoholics Anonymous). However, the use of pharmacotherapy may complement psychosocial treatments, as evidence shows that pharmacotherapy can improve treatment outcomes. The effectiveness of pharmacotherapy depends on patient compliance with taking the medication and the context in which the medication is administered. BRENDA is a psychosocial program designed specifically to be used by many types of healthcare providers, including primary care clinicians. Designed to enhance medication and treatment compliance, BRENDA is an ideal approach for use in conjunction with pharmacotherapy. The BRENDA approach has 6 components: 1) a biopsychosocial evaluation; 2) a report of findings from the evaluation given to the patient; 3) empathy; 4) addressing patient needs; 5) providing direct advice; and 6) assessing patient reaction to advice and adjusting the treatment plan as needed. This paper describes these components and discusses how the empirical support for each component is linked to the enhancement of medication compliance and the improvement of treatment outcomes.

Aims

We conducted a review of published reports of smoking cessation pharmacotherapy trials in order to address the following: 1) the generalizability of findings to smokers with a history of alcohol problems; 2) the extent to which alcohol use affects smoking cessation overall and the efficacy of pharmacotherapy specifically and 3) the effect of smoking cessation on alcohol use.

Methods

We located published reports of nicotine replacement therapy (NRT), bupropion sustained release (SR) and varenicline clinical trials using an approach based on prior Cochrane reviews. The reports were searched for alcohol-related inclusion/exclusion criteria and for findings related to alcohol.

Results

The present review included 212 published reports from 149 trials. Alcohol-related exclusion criteria appeared frequently (41.6% of trials)—45/125 NRT trials (36%), 15/22 bupropion SR trials (68.2%) and 3/3 varenicline trials—and most commonly involved exclusion of participants with either current or recent alcohol problems. Most studies failed to provide any baseline alcohol-related characteristics. Eleven trials reported on the relationship between alcohol history and likelihood of smoking cessation. In the majority of these studies, smokers with a past history of alcohol problems were not at a disadvantage, although contrary findings exist. Only two studies examined the potential influence of smoking cessation on alcohol use.

Conclusions

Smokers with alcohol problems, particularly those with current or recent problems, are underrepresented in studies of approved pharmacotherapy for smoking cessation. Future trials should assess alcohol use at baseline and during treatment and examine reciprocal influences between alcohol consumption and smoking cessation.

Links between trait disinhibition and high-risk drinking are well established. It is also known that alcohol has disinhibiting effects. Nonetheless, there is no measure in the literature devoted exclusively to assessing disinhibiting effects of alcohol. The multidimensional Drinking-Induced Disinhibition Scale (DIDS) was developed as part of Study I, a prospective survey conducted with undergraduates (N = 337). Study II, a cross-sectional survey (N = 260), allowed for a confirmatory factor analysis and further validation of the measure through comparisons with an expectancies scale. The nine-item DIDS is comprised of three subscales assessing euphoric/social, dysphoric and sexual disinhibition. All three subscales had good internal consistency and adequate test-retest reliability. Convergent and discriminant validity were established in both studies. The subscales had different associations with high-risk drinking: sexual disinhibition predicted heavy episodic drinking; dysphoric disinhibition predicted alcohol-related problems and euphoric/social had associations with both. A cluster analysis revealed four distinct disinhibition profiles (i.e., low effect drinker; high euphoric/social only; high euphoric social and dysphoric; high euphoric/social and sexual), which predicted likelihood of high-risk drinking.

Limiting attrition (i.e., participant dropout before the conclusion of a study) is a major challenge faced by researchers when implementing clinical trials. Data from a smoking cessation trial for females (N = 246) were analyzed in order to identify baseline smoking-related, demographic and psychological characteristics affecting likelihood of early (i.e., before the quit attempt) and late (i.e., after the quit attempt) dropout. There were a number of significant demographic predictors of attrition. Participants with at least one child living at home were at increased risk of both early and late dropout. Non-Whites were at increased risk of early dropout, while not having a college degree put one at increased risk of late dropout. Age was found to be a protective factor in that the older a participant was, the less likely she was to drop out in the early stages of the trial. With respect to psychological variables, weight concerns increased risk of attrition, as did the experience of guilt. In terms of smoking-related variables, mean cigarettes per day was not a significant predictor of attrition, although length of longest prior quit attempt was a significant predictor of early dropout when age was removed from the regression.

Background

We examined female sedentary smokers' additional cardiovascular disease (CVD) risk behaviors and their associations to smoking cessation.

Methods

This study was part of a randomized controlled trial testing the effectiveness of exercise and nicotine gum in smoking cessation. Included in the analyses were 148 participants. Dietary habits and alcohol consumption were measured as additional CVD risk behaviors. High-fat diet and heavy alcohol use were considered those risk behaviors. Nicotine dependence, length of the longest quit attempt, depressive symptoms, self-efficacy, and education were examined as other baseline variables. Abstinence from tobacco was recorded through 12 months.

Results

Diet was related to depressive symptoms at baseline. Alcohol use was related to nicotine dependence and education level. Heavy alcohol use alone and accumulation of two added risk behaviors predicted poorer smoking cessation outcome. Although diet alone was not associated with cessation outcome the high-fat diet interacted with depressive symptoms, such that the depressed women with high-fat diet were significantly more likely to relapse in their quit attempt compared to other subgroups.

Conclusion

Non-moderate alcohol use alone and accumulation of multiple CVD risk behaviors seem to be associated with lower success in smoking cessation.