Reactivity to smoking-related cues may be an important factor that precipitates relapse in smokers who are trying to quit. The neurobiology of smoking cue reactivity has been investigated in several fMRI studies. We combined the results of these studies using activation likelihood estimation, a meta-analytic technique for fMRI data. Results of the meta-analysis indicated that smoking cues reliably evoke larger fMRI responses than neutral cues in the extended visual system, precuneus, posterior cingulate gyrus, anterior cingulate gyrus, dorsal and medial prefrontal cortex, insula, and dorsal striatum. Subtraction meta-analyses revealed that parts of the extended visual system and dorsal prefrontal cortex are more reliably responsive to smoking cues in deprived smokers than in non-deprived smokers, and that short-duration cues presented in event-related designs produce larger responses in the extended visual system than long-duration cues presented in blocked designs. The areas that were found to be responsive to smoking cues agree with theories of the neurobiology of cue reactivity, with two exceptions. First, there was a reliable cue reactivity effect in the precuneus, which is not typically considered a brain region important to addiction. Second, we found no significant effect in the nucleus accumbens, an area that plays a critical role in addiction, but this effect may have been due to technical difficulties associated with measuring fMRI data in that region. The results of this meta-analysis suggest that the extended visual system should receive more attention in future studies of smoking cue reactivity.

Background

Negative affect is an important predictor of smoking behavior, and many smokers believe that smoking reduces negative affect. However, it is unclear whether such beliefs, known as negative reinforcement smoking outcome expectancies (NRSOE), are associated with changes in negative affect in response to nicotine deprivation and administration.

Methods

Smokers (N = 114) participated in 4 sessions that balanced overnight smoking deprivation (12-hr deprived vs. ad lib) and nasal spray administration (nicotine vs. placebo). Corrugator supercilii (COR) EMG, skin conductance (SCR), and in-session ratings were collected while the participants viewed affective, cigarette-related, and neutral slides. Retrospective questionnaire data were collected prior to slide viewing. NRSOE were determined using the Smoking Consequences Questionnaire-Adult Nicotine Affect Reduction scale (SCQ-NAR).

Results

High scores on the SCQ-NAR were associated with smaller COR EMG to unpleasant slides following nicotine nasal spray administration compared to placebo spray, regardless of overnight deprivation. Smokers who had high scores on the SCQ-NAR had smaller SCR, following nicotine nasal spray administration compared to placebo spray, but only after overnight deprivation. The in-session ratings and retrospective questionnaire measures indicated that smokers who had high scores on the SCQ-NAR experienced greater negative affect and craving, and less positive affect, than smokers with low scores on the SCQ-NAR, regardless of nicotine exposure.

Conclusions

Our questionnaire results suggest that while smokers who have high NRSOE self-report greater overall levels of negative affect and craving, while the psychophysiological data suggest that such smokers may experience negative affect reduction when blindly administered a dose of nicotine.

Introduction:

Little is known about the influence of prepartum menthol cigarette use on postpartum smoking abstinence or how race/ethnicity might moderate this relationship. The current study addressed that gap by testing these relationships among racially/ethnically diverse women who quit smoking during pregnancy (N = 244; 33% African American, 31% Latina, 36% White).

Methods:

Continuation ratio logit models were used to examine the effects of prepartum menthol cigarette use on biochemically confirmed, continuous abstinence through 26 weeks postpartum using an intent-to-treat approach. Analyses controlled for age, race/ethnicity, partner status, income, education, treatment, number of prequit cigarettes smoked per day, time to the first cigarette of the day, and time (Week 8 or 26 data collection timepoint). An additional model tested the moderating effects of race/ethnicity by including an interaction term.

Results:

Prepartum menthol cigarette use was not significantly associated with postpartum smoking abstinence in the overall sample. However, the interaction between menthol use and race/ethnicity was significant (p = .02). Among White women, menthol use was associated with significantly lower odds of maintaining postpartum smoking abstinence (p = .03; odds ratio = .19 [.04–.89]), and the effect approached significance among African American women (p = .08).

Conclusions:

This study provides the first evidence that prepartum menthol cigarette use may increase the risk of postpartum smoking relapse among White, and possibly African American, women who quit smoking during or immediately before pregnancy. Results suggest that White and African American prepartum menthol users may require different or more intensive cessation services to aid in the maintenance of postpartum smoking abstinence. Replication with larger samples, and a focus on understanding the mechanisms that underlie these relationships, are warranted.

Chronic smoking is thought to cause changes in brain reward systems that result in overvaluation of cigarette-related stimuli and undervaluation of natural rewards. We tested the hypotheses that, in smokers, brain circuits involved in emotional processing 1) would be more active during exposure to cigarette-related than neutral pictures, and 2) would be less active to pleasant compared to cigarette-related pictures, suggesting a devaluation of intrinsically pleasant stimuli. We obtained whole brain blood-oxygenation-level-dependent functional magnetic resonance imaging (BOLD fMRI) data from 35 smokers during the presentation of pleasant (erotica and romance), unpleasant (mutilations and sad), neutral, and cigarette-related pictures. Whole brain analyses showed significantly larger BOLD responses during presentation of cigarette-related pictures relative to neutral ones within the secondary visual areas, the cingulate gyrus, the frontal gyrus, the dorsal striatum, and the left insula. BOLD responses to erotic pictures exceeded responses to cigarette-related pictures in all clusters except the insula. Within the left insula we observed larger BOLD responses to cigarette-related pictures than to all other picture categories. By including intrinsically pleasant and unpleasant pictures in addition to neutral ones, we were able to conclude that the presentation of cigarette-related pictures activates brain areas supporting emotional processes, but we did not find evidence of overall reduced activation of the brain reward systems in the presence of intrinsically pleasant stimuli.

Introduction:

Research indicates that negative affect and/or depression is associated with increased prevalence for smoking and higher levels of nicotine dependence in adults and adolescents. A previous study with adult smokers attempting to quit indicated that low levels of self-efficacy partially mediated depression's adverse effect on posttreatment cessation.

Method:

The current study attempted to test self-efficacy as a potential mediator between depressive symptoms and smoking susceptibility in adolescents. One thousand and ninety-three nonsmoking high-school students who were part of a large clinical trial evaluating an interactive CD-ROM–based smoking prevention/cessation curriculum (project ASPIRE) were included in this analysis. These students completed an extensive battery before treatment and 18 months after treatment, which included measures of depression, self-efficacy, smoking status, and smoking susceptibility.

Results:

Results indicated that self-efficacy partially mediated the positive relationship between baseline depressive symptoms and susceptibility to smoke at 18 months, accounting for approximately 27% of the variance.

Conclusions:

Perhaps future interventions to prevent smoking in adolescents can target self-efficacy potentially resulting in more effective outcomes, particularly in adolescents with current depressive symptoms or who may be at risk for future depression.

Introduction:

The Wisconsin Smoking Withdrawal Scale (WSWS) is a valid and reliable scale among non-Latino Whites but has not been validated for use among other racial/ethnic groups despite increasing use with these populations. The current study examined the structural invariance and predictive equivalency of the WSWS across three racial/ethnic groups.

Methods:

The WSWS scores of 424 African American, Latino, and White smokers receiving smoking cessation treatment were analyzed in a series of factor analyses and multiple-group analyses. Additionally, hierarchical logistic regression analyses were conducted to determine whether WSWS scores differentially predicted smoking relapse across racial/ethnic groups. These analyses were consistent with a step-down hierarchical regression procedure for examination of test bias.

Results:

The 7-factor structure of the WSWS was largely confirmed in the current study, with the exception of the removal of two offending items. Evidence of full invariance across race/ethnicity was found in multiple-group analyses. The WSWS total score and subscales measuring anger, anxiety, concentration, and sadness predicted relapse, whereas the hunger, craving, and sleep subscales did not. None of these scales displayed differential predictive ability across race/ethnicity. The WSWS sleep subscale showed a significant interaction with race/ethnicity such that it was a significant predictor of relapse among Whites but not African Americans or Latinos.

Conclusions:

Overall, the WSWS is similar in structure and predictive of relapse across racial/ethnic groups. Caution should be exercised when using the WSWS sleep subscale with African Americans and Latinos.

Background

The current study evaluated the efficacy of an individualized, hand-held Computer-Delivered Treatment (CDT) versus Standard Treatment (ST) for the maintenance of smoking abstinence following a quit attempt.

Methods

Participants were 303 adult daily smokers randomized to CDT or ST, plus pharmacotherapy. Abstinence though one year was examined using logistic random intercept models, a type of generalized linear mixed model regression.

Results

Results did not support the efficacy of the CDT program through one year post-quit in analyses adjusted for time and study site [OR = .84, 95% CI = .55–1.30], or after further adjusting for race/ethnicity, age, gender, education, marital status, and the number of cigarettes smoked per day before quitting [OR = .89, 95% CI = .57–1.39].

Conclusions

CDT did not increase short- or long-term abstinence rates over ST in this study.

Impact Statement

Findings differ from some in the literature and suggest the need for continued research on the use of CDT for smoking cessation.

Affective startle probe methodology was used to examine the effects of nicotine administration and deprivation on emotional processes among individuals carrying at least one s allele versus those with the l/l genotype of the 5-Hydroxytryptamine (Serotonin) Transporter Linked Polymorphic Region, 5-HTTLPR in the promoter region of the serotonin transporter gene [Solute Ligand Carrier family 6 member A4 (SLC6A4) or SERT]. Smokers (n = 84) completed four laboratory sessions crossing deprivation (12-hour deprived vs. non-deprived) with nicotine spray (nicotine vs. placebo). Participants viewed affective pictures (positive, negative, neutral) while acoustic startle probes were administered. We found that smokers with the l/l genotype showed significantly greater suppression of the startle response when provided with nicotine vs. placebo than those with the s/s or s/l genotypes. The results suggest that l/l smokers, who may have higher levels of the serotonin transporter and more rapid synaptic serotonin clearance, experience substantial reduction in activation of the defensive system when exposed to nicotine.

Addiction has been described as the pathological usurpation of the neural mechanisms normally involved in emotional processing. Event-related potentials (ERPs) can provide a noninvasive index of neural responses associated with the processing of emotionally relevant stimuli and serve as a tool for examining temporal and spatial commonalities between the processing of intrinsically motivating stimuli and drug cues. Before beginning a smoking cessation program, 116 smokers participated in a laboratory session in which dense-array ERPs (129 sensors) were recorded during the presentation of pictures with emotional (pleasant and unpleasant), neutral, and cigarette-related content. ERP differences among categories were analyzed with use of randomization tests on time regions of interest identified by temporal principal component analysis. Both emotional and cigarette-related pictures prompted significantly more positivity than did neutral pictures over central, parietal, and frontal sites in the 452–508 ms time window. During the 212–316 ms time window, both pleasant and cigarette-related pictures prompted less positivity than neutral images did. Cigarette-related pictures enhanced the amplitude of the P1 component (136–144 ms) above the levels measured in the emotional and neutral conditions. These results support the hypothesis that for smokers, cigarette-related cues are motivationally relevant stimuli that capture attentional resources early during visual processing and engage brain circuits normally involved in the processing of intrinsically emotional stimuli.

The Implicit Association Test (IAT) has been used to assess automatic affective responses to drug cues. Smokers (N = 57) completed the IAT at four experimental sessions. They abstained from smoking before two of the sessions (AB), and smoked normally before the other two sessions (NON). At one AB (and NON) session, they smoked a cigarette about 40 minutes before completing the IAT (S), and at the other they did not smoke (NS). Overall, participants exhibited a negative IAT effect, indicating that they found the classification task easier when smoking was paired with bad than when smoking was paired with good. Using repeated measures ANOVA, the IAT effect was made less negative by pre-session Abstinence, and made more negative by Smoking. It was most negative in the NON-S condition. Using Generalized Estimating Equations analyses, the IAT effect was positively associated with pre-task craving ratings assessed on the Questionnaire of Smoking Urges-Brief, but was not associated with a physiological measure of automatic affective responses (startles while viewing smoking vs. neutral pictures). The IAT effect was associated with scores on the Fagerstrom Test for Nicotine Dependence. In sum, automatic affective responses assessed with the smoking IAT are associated with measures of smoking motivation and dependence.

Introduction:

Current smoking cessation guidelines recommend setting a quit date prior to starting pharmacotherapy. However, providing flexibility in the date of quitting may be more acceptable to some smokers. The objective of this study was to compare varenicline 1 mg twice daily (b.i.d.) with placebo in subjects using a flexible quit date paradigm after starting medication.

Methods:

In this double-blind, randomized, placebo-controlled international study, smokers of ≥10 cigarettes/day, aged 18–75 years, and who were motivated to quit were randomized (3:1) to receive varenicline 1 mg b.i.d. or placebo for 12 weeks. Subjects were followed up through Week 24. Subjects were instructed to quit between Days 8 and 35 after starting medication. The primary endpoint was carbon monoxide–confirmed continuous abstinence during Weeks 9–12, and a key secondary endpoint was continuous abstinence during Weeks 9–24.

Results:

Overall, 493 subjects were randomized to varenicline and 166 to placebo. Continuous abstinence was higher for varenicline than for placebo subjects at the end of treatment (Weeks 9–12: 53.1% vs. 19.3%; odds ratio [OR] 5.9; 95% CI, 3.7–9.4; p < .0001) and through 24 weeks follow-up (Weeks 9–24: 34.7% vs. 12.7%; OR 4.4; 95% CI, 2.6–7.5; p < .0001). Serious adverse events occurred in 1.2% varenicline (none were psychiatric) and 0.6% placebo subjects. Fewer varenicline than placebo subjects reported depression-related adverse events (2.3% vs. 6.7%, respectively).

Conclusions:

Varenicline 1 mg b.i.d. using a flexible quit date paradigm had similar efficacy and safety compared with previous fixed quit date studies.

Introduction:

The purpose of this study was to characterize the relationship between breast feeding and postpartum smoking abstinence among women who quit smoking due to pregnancy and who were participating in a randomized clinical trial of an intervention designed to prevent postpartum relapse.

Methods:

A total of 251 women were enrolled in the intervention between 30 and 33 weeks postpartum and were followed through 26 weeks postpartum. Participant characteristics were assessed at the prepartum baseline visit, any breast feeding was assessed at 8 weeks postpartum, and smoking abstinence was assessed at 8 and 26 weeks postpartum.

Results:

Although 79.1% of participants intended to breast feed, only 40.2% reported breast feeding at 8 weeks postpartum. Characteristics associated with breast feeding at 8 weeks postpartum included Caucasian race/ethnicity, greater education, higher household income, and being married/living with a significant other. Logistic regression analysis indicated that breast feeding at 8 weeks postpartum was significantly associated with smoking abstinence at 8 weeks postpartum, odds ratio (OR) = 7.27 (95% CI = 3.27, 16.13), p < .001. Breast feeding at 8 weeks postpartum was also associated with abstinence at 26 weeks postpartum after controlling for smoking status at 8 weeks postpartum, OR = 2.64 (95% CI = 1.14, 6.10), p = .02.

Discussion:

Encouraging breast feeding among women who quit smoking due to pregnancy may facilitate postpartum smoking abstinence while increasing adherence to current infant feeding guidelines.

Objectives

Direct and mediated associations between subjective social status (SSS), a subjective measure of socioeconomic status, and smoking abstinence were examined during the period of acute withdrawal among a diverse sample of 421 smokers (33% Caucasian, 34% African-American, 33% Latino) undergoing a quit attempt.

Methods

Logistic regressions examined relations between SSS and abstinence, controlling for sociodemographic variables. Depression, stress, positive affect, and negative affect on the quit day were examined as potential affective mediators of the SSS-abstinence association, with and without adjusting for pre-quit mediator scores.

Results

SSS predicted abstinence through 2 weeks post-quit. Abstinence rates were approximately 2.5 times higher in the highest versus the lowest SSS quartile. Depression and positive affect mediated the SSS-abstinence relationships, but only depression maintained significance when adjusting for the baseline mediator score.

Conclusions

Among a diverse sample of quitting smokers, low SSS predicted relapse during acute withdrawal after controlling for numerous covariates, an effect partially accounted for by quit day affective symptomatology. Smokers endorsing lower SSS face significant hurdles in achieving cessation, highlighting the need for targeted interventions encompassing attention to quit day mood reactivity.

Introduction:

The 68-item Wisconsin Inventory of Smoking Dependence Motives (WISDM-68) is a theoretically derived measure of tobacco dependence consisting of 13 subscales measuring a variety of smoking motives. The WISDM-68 subscales have demonstrated good psychometric characteristics and have the potential to elucidate diverse nicotine dependence factors and mechanisms. The present research aimed to shorten the WISDM to reduce assessment burden while maintaining or enhancing its psychometric properties.

Methods:

Data from three independent samples (one longitudinal observational study and two randomized clinical trials) were used to select subscales and reduced sets of items in order to develop and test a brief version of the WISDM-68. The full-item and reduced-item versions of the WISDM were then compared in terms of reliability, validity, and model fit (via confirmatory factor analysis) in the three independent samples.

Results:

Thirty-one items were dropped from the WISDM, the Behavioral Choice–Melioration subscale was dropped, and the Negative and Positive Reinforcement subscales were consolidated. This resulted in a new WISDM short form (Brief WISDM) comprising 37 items that load onto 11 subscales. The psychometric properties of the reduced-item WISDM subscales were found to be comparable with the full-item subscales in terms of internal consistency, long-term stability, concurrent validity, predictive validity, and model fit.

Discussion:

These analyses provide good evidence that the 37-item Brief WISDM can be used in place of the original 68-item WISDM if researchers desire to reduce participant assessment burden.

Objective

Although there has been a socioeconomic gradient in smoking prevalence, cessation, and disease burden for decades, these disparities have become even more pronounced over time. The aim of the current study was to develop and test a conceptual model of the mechanisms linking socioeconomic status (SES) to smoking cessation.

Design

The conceptual model was evaluated using a latent variable modeling approach in a sample of 424 smokers seeking treatment (34% African American; 33% Latino; 33% White). Hypothesized mechanisms included social support, neighborhood disadvantage, negative affect/stress, agency, and craving.

Main Outcome Measure

The primary outcome was week 4 smoking status.

Results

As hypothesized, SES had significant direct and indirect effects on cessation. Specifically, neighborhood disadvantage, social support, negative affect/stress, and agency mediated the relation between SES and smoking cessation. A multiple group analysis indicated that the model was a good fit across racial/ethnic groups.

Conclusion

The present study yielded one of the more comprehensive models illuminating the specific mechanisms that link SES and smoking cessation. Policy, community, and individual-level interventions that target low SES smokers and address the specific pathways identified in the current model could potentially attenuate the impact of SES on cessation.

Introduction:

Postpartum relapse rates are high among women who spontaneously quit smoking during pregnancy. This randomized clinical trial tested a Motivation and Problem-Solving (MAPS) treatment for reducing postpartum relapse among diverse low-income women who quit smoking during pregnancy (N = 251; 32% Black, 30% Latino, and 36% White; 55% <$30,000/year household income).

Methods:

Pregnant women were randomly assigned to MAPS/MAPS+ or Usual Care (UC). Continuation ratio logit models were used to examine differences in biochemically confirmed continuous abstinence at Weeks 8 and 26 postpartum by treatment group and moderators of the treatment effect. Analyses controlled for age, race/ethnicity, partner status, education, smoking rate, and the number of smokers in the participant’s environment.

Results:

MAPS/MAPS+ was more efficacious than UC in the prevention of postpartum relapse (p = .05). An interaction between treatment and the number of cigarettes smoked per day before quitting approached significance (p = .09), suggesting that the MAPS/MAPS+ treatment effect was stronger among women who smoked more cigarettes per day.

Discussion:

MAPS, a holistic and dynamic approach to changing behavior using a combined motivational enhancement and social cognitive approach, is a promising intervention for postpartum smoking relapse prevention among low-income women, which may have particular relevance for women with higher prequit smoking rates.

Objective

The objective of this study was to evaluate a depression-focused treatment for smoking cessation in pregnant women, versus a time and contact health education control. We hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized.

Method

Pregnant smokers (N=257) were randomly assigned to a 10- week intensive depression-focused intervention (Cognitive Behavioral Analysis System of Psychotherapy-CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Fifty-four percent of the sample was African American; 37% met DSM-IV criteria for major depression; mean age (SD) was 25 (5.9) and women averaged 19.5 (8.5) weeks gestation at study entry. Ongoing symptoms of depression were measured using the Center for Epidemiological Studies Depression scale (CES-D).

Results

The results showed that at 6-months posttreatment, women with higher levels of baseline depressive symptoms treated with CBASP had a higher probability of prolonged abstinence (F(1,253)=5.61, p=.02) and more improved depression (F(1,2620)=10.49, p=.001) than those treated with HW, whereas those with low baseline depression fared better in HW. The differences in abstinence were not retained at 6-months postpartum.

Conclusions

The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health.

Although socioeconomic status is a major contributing factor to health disparities, the mechanisms through which socioeconomic status influences health remain unclear. The purpose of the present study was to evaluate an a priori conceptual model of the pathways between socioeconomic status and modifiable health risk factors in a sample of 399 African Americans seeking smoking cessation treatment. A latent variable modeling approach was utilized to characterize the interrelationships among socioeconomic status, neighborhood disadvantage, social support, negative affect/perceived stress, and three specific modifiable risk factors (i.e., overweight/obesity, insufficient physical activity, at-risk drinking). Findings indicated that neighborhood disadvantage, social support, and negative affect/perceived stress function as pathways linking socioeconomic status and modifiable risk factors among African American smokers, and negative affect/perceived stress appears to play a key mediating role. Policy, community, and individual-level interventions may attenuate the impact of socioeconomic status on health by targeting intermediate psychosocial, environmental, and behavioral pathways.

Introduction:

Numerous studies report smokers’ increased craving and physiological arousal when exposed to cigarette stimuli. These responses are attributed to learning processes (e.g., classical conditioning) and are associated with motivational factors that maintain nicotine dependence. However, much less is known about the degree to which these responses are maintained or diminished during quitting.

Methods:

Treatment-seeking smokers (N = 104) were randomly assigned to continue smoking or to enter a 2-week treatment program. Abstainers (n = 25) were continuously abstinent for 14–17 days at the time of testing. Control subjects (n = 38) continued to smoke at their usual rate. Participants who were assigned to treatment but resumed smoking during the study (n = 41) were considered to be relapsers. Approximately 2 weeks after baseline measurements, abstainers and controls viewed a series of neutral (n = 12) and cigarette (n = 12) pictures, rating them for craving and arousal (feelings of calm vs. excitement).

Results:

Non-cued craving (measured during exposure to neutral cues) was diminished in abstaining smokers. However, cigarette cues produced craving increases of the same magnitude in both abstainers and controls, showing that these cues still had evocative power for both groups. Abstaining smokers, who were not physiologically monitored, had lower self-reports of arousal to cigarette pictures than did controls, but the groups did not differ in arousal to neutral pictures.

Discussion:

These findings suggest that the foundations of cue-induced craving, generalized craving, and physiological arousal associated with craving may arise from separate processes.

The majority of smoking cessation research has focused on heavy smokers. African Americans (AA) are less likely than the general population to be heavy smokers. Thus, little is known about the smoking and psychosocial characteristics of lighter AA smokers. The present study compared the baseline demographic, smoking, and psychosocial characteristics of light (5-10 cigarettes per day; n = 86) and moderate to heavy (> 10 cigarettes per day; n = 286) AA smokers enrolled in a smoking cessation clinical trial. Results indicated no differences between groups on demographic variables. However, light smokers (LS) were less dependent on smoking, reported more previous quit attempts, and had higher self-efficacy to quit than moderate to heavy smokers (MHS). On a measure of withdrawal, LS reported less pre-quit craving and less difficulty concentrating than MHS. In addition, LS reported lower perceived stress, fewer symptoms of depression, and greater positive affect than AA MHS. These findings highlight important similarities and differences between AA LS and MHS, and have implications for the treatment of AA smokers.

Research suggests that there are racial disparities in smoking behaviors, cessation rates, mortality, and morbidity. However, little is known regarding racial differences in affect regulation by smoking. The purpose of this study was to examine racial differences in the effects of nicotine deprivation and administration on smokers’ startle responding to smoking and affective cues. 104 African American (AA) and Caucasian American (CA) smokers completed 4 laboratory sessions crossing nicotine deprivation (12-hour deprived vs. nondeprived) with nicotine nasal spray (active vs. placebo). Participants viewed affective (positive, neutral, and negative) and smoking slides while startle probes were administered. The results showed that relative to placebo, AA smokers given nicotine spray exhibited significantly lower startle responses when they were exposed to smoking cues and CA smokers given nicotine spray exhibited significantly lower startle responses when they were exposed to negative and neutral cues. Although nicotine suppresses startle responding in both AA and CA smokers, the effect is modulated by different cue conditions, suggesting that there may be racial differences in components of smoking motivation.

The purpose of the present study was to describe the prevalence, patterns, and predictors of co-occurring modifiable cancer risk factors among African Americans seeking smoking cessation treatment, and to evaluate previously hypothesized models of the relationship between socioeconomic status and health behavior. Overweight/obesity, at-risk alcohol consumption, and insufficient physical activity were measured in 399 African American smokers. Analyses indicated that 92.8% of participants had at least one cancer risk factor in addition to smoking. Univariate ordinal logistic regression analyses revealed that female gender, unemployment, lower positive affect and greater negative affect were associated with having a greater number of cancer risk factors. Multivariate analyses yielded similar findings. A structural equation modeling approach indicated that stress/negative affect may function as one pathway linking socioeconomic status and modifiable cancer risk factors among African American smokers, and that gender has a direct effect on modifiable cancer risk factors. Thus, risk patterns identified within each gender group may guide the development of multiple risk factor interventions for African American smokers. Stress and negative affect may be an important treatment target within behavioral interventions for African American smokers of low socioeconomic status.

Objective

Motivation plays an important role in a variety of behaviors, including smoking cessation, and is integral to theory and treatment of smoking. For many women, pregnancy offers a motivational shift that helps them stop smoking and maintain abstinence during pregnancy. However, women's motivation to maintain smoking abstinence postpartum is not well-understood and may play a role in high postpartum relapse rates. The current study utilized multiple measures of prepartum motivation to maintain smoking abstinence to predict postpartum smoking abstinence.

Design

As part of a randomized clinical trial on postpartum smoking relapse prevention, pregnant women who quit smoking during pregnancy reported their motivation to continue smoking abstinence at a prepartum baseline session. Continued smoking abstinence was assessed at 8 and 26 weeks postpartum.

Main Outcome Measure

Biochemically verified continuous abstinence from smoking.

Results

Direct relationships among multiple measures of motivation were significant, and ranged in strength from weak to moderate. All motivation measures individually predicted continuous smoking abstinence, after controlling for treatment group, demographics, and pre-quit tobacco use. When tested simultaneously, a global motivation measure and parenthood motives for quitting remained significant predictors of abstinence. Backward selection modeling procedures resulted in a reduced model of prepartum predictors of postpartum abstinence including global motivation, parenthood motives, and stage of change.

Conclusion

Global motivation for smoking abstinence and parenthood motives for quitting are particularly important motivational constructs for pregnant women's continued smoking abstinence.

A mediation model explores the direct and indirect effects between an independent variable and a dependent variable by including other variables (or mediators). Mediation analysis has recently been used to dissect the direct and indirect effects of genetic variants on complex diseases using case-control studies. However, bias could arise in the estimations of the genetic variant-mediator association because the presence or absence of the mediator in the study samples is not sampled following the principles of case-control study design. In this case, the mediation analysis using data from case-control studies might lead to biased estimates of coefficients and indirect effects. In this article, we investigated a multiple-mediation model involving a three-path mediating effect through two mediators using case-control study data. We propose an approach to correct bias in coefficients and provide accurate estimates of the specific indirect effects. Our approach can also be used when the original case-control study is frequency matched on one of the mediators. We employed bootstrapping to assess the significance of indirect effects. We conducted simulation studies to investigate the performance of the proposed approach, and showed that it provides more accurate estimates of the indirect effects as well as the percent mediated than standard regressions. We then applied this approach to study the mediating effects of both smoking and chronic obstructive pulmonary disease (COPD) on the association between the CHRNA5-A3 gene locus and lung cancer risk using data from a lung cancer case-control study. The results showed that the genetic variant influences lung cancer risk indirectly through all three different pathways. The percent of genetic association mediated was 18.3% through smoking alone, 30.2% through COPD alone, and 20.6% through the path including both smoking and COPD, and the total genetic variant-lung cancer association explained by the two mediators was 69.1%.

We used multimodal measurement to evaluate whether (a) nicotine dependence is associated with baseline and postquit negative affect and craving, (b) smoking relapse is associated with greater negative affect and craving than abstinence, and (c) craving is associated with negative affect. Treatment-seeking smokers were randomly assigned to either a brief behaviorally based smoking-cessation treatment condition or to a delayed treatment control condition. Participants in the treatment condition attended four assessment sessions, 4 –5 days prequit (baseline), 1–2 days postquit, 3–5 days postquit, and 10 –14 days postquit, while controls attended four sessions spaced over the same intervals. Retrospective questionnaires were collected at the beginning of each session, and corrugator EMG and in-session ratings were collected during viewing of affective and cigarette-related slides. The multimodal measures indicated that more dependent smokers experienced greater negative affect and craving at baseline and postquit, regardless of abstinence status. The self-report measures indicated that both relapsed and abstinent smokers reported greater negative affect and craving than control smokers. Craving was associated with negative affect across measurement modalities. These results highlight the benefits of using multimodal measures to study the impact of nicotine dependence and withdrawal on negative affect and craving.