Regulation of craving by cognitive strategies in cigarette smokers

Abstract

Cigarette craving is an important contributor to cigarette smoking, and clinical approaches that focus on regulation of craving are effective in reducing rates of relapse. However, a laboratory model that targets the use of cognitive strategies to regulate craving is lacking. To develop such a model, twenty heavy cigarette smokers (>12/day), twenty-two tobacco “chippers” (<6/day), and twenty non-smoking controls completed this outpatient study, during which they were presented with photographs of cigarettes and foods that have been previously shown to induce craving. During each trial, participants were instructed to think of the stimulus in one of two ways: by focusing either on the short-term consequences associated with consuming the item (e.g., it will taste good) or on the long-term consequences associated with regular consumption (e.g., I may get lung cancer). Participants reported significantly reduced food cravings when focusing on the long-term consequences associated with eating. For cigarette-smoking participants, cigarette craving was significantly reduced when focusing on the long-term consequences associated with smoking. This latter finding confirms clinical data and extends it by highlighting the importance of cognition in the modulation of craving. Future studies using this laboratory model could test the efficacy of different cognitive strategies and develop targeted interventions for smoking cessation based on the regulation of craving.

Introduction

In the United States, there are more than 430,000 smoking-attributable deaths each year (Center for Disease Control and Prevention, 2007), which has earned cigarette smoking the distinction of being the leading preventable cause of disease and death in the United States. Despite this fact, 60 million Americans smoke cigarettes, and nearly 40 million of them are daily smokers (Substance Abuse and Mental Health Services Administration, 2008). Indeed, while considerable efforts have been devoted to the development of smoking cessation treatments, the modal outcome for these interventions is smoking relapse (Fiore et al., 2000, Piasecki, 2006).

Craving has long been considered an important contributory factor in cigarette smoking. Data from clinical research have shown that the degree of craving for cigarettes increases prior to relapse (Allen et al., 2008, Shiffman et al., 1996). Moreover, craving has been found to predict relapse in several prospective studies (Catley et al., 2000, Killen and Fortmann, 1997, O’Connell et al., 2004, Shiffman et al., 1997). One potent trigger for craving is exposure to smoking cues, such as photos depicting others smoking (Carter and Tiffany, 1999, Conklin et al., 2000, McBride et al., 2006, Mucha et al., 1999). Such cue exposure elicits both classically and operantly conditioned craving responses (Kober et al., 2009), renders smokers particularly vulnerable to cigarette use (Tiffany, 1990), and increases the likelihood of relapse in the context of smoking cessation (Bliss et al., 1989, Shiffman et al., 1996). Further, data from experimental paradigms directly links increased cue exposure to increased smoking behavior (Payne et al., 1991).

Although craving is not the only factor that leads to drug use (e.g., Tiffany and Carter, 1998), these data indicate that craving is associated with cigarette smoking, and further suggest that cigarette smoking and relapse rates could be decreased by regulation of craving. This has not been studied experimentally, but this idea is consistent with data showing that cognitive-behavioral and relapse prevention approaches that include the use of cognitive strategies for regulation of craving are effective at reducing craving across various substance use disorders (Carroll, 1996, McCrady and Ziedonis, 2001). In cigarette smokers, cognitive coping strategies have been shown to reduce craving as well as reduce instances of relapse during smoking cessation (Bliss et al., 1989, Bliss et al., 1999, O’Connell et al., 2007, Shiffman et al., 1996).

The above suggest that the effective use of cognitive strategies can reduce both craving and smoking behavior in cigarette smokers. Yet, a few important questions remain unresolved. First, the modulatory effect of cognitive strategies on craving has not been studied in a laboratory model under controlled conditions. Although a few laboratory studies have demonstrated that craving predicts preferences for cigarettes over monetary rewards (Bisaga et al., 2007) or the willingness to work for cigarettes (Willner et al., 1995), none have directly examined the modulatory effects of specific cognitive strategies on craving. Second, the effects of different cognitive strategies on craving have not been directly compared. Cognitive-behavioral approaches to smoking cessation often include a component targeting regulation of craving (McDonald et al., 2003, Piasecki and Baker, 2001, Shiffman, 1993), but they are not designed to determine which specific strategies are most effective in reducing craving. Addressing these two questions should contribute to our understanding of why specific cognitive strategies are effective for curbing smoking behavior and could provide the basis for developing targeted interventions for smoking cessation.

We addressed these issues in a novel paradigm that combines elements of studies of cue-induced craving and emotion regulation. Cigarette smoking and non-smoking participants were first trained to use two cognitive strategies, adapted from studies showing that affective responses can be modulated by consciously controlling how one cognitively appraises the meaning of affect-eliciting stimuli (Mischel et al., 1989, Ochsner and Gross, 2005). Participants then completed a series of trials where these strategies were used to enhance or reduce their craving for cigarettes, using cues that have been previously shown to induce craving in cigarette smokers (Mucha et al., 1999). Photographs of high-calorie foods also were used as control stimuli to determine whether smokers differed specifically in their craving for cigarettes. Craving was operationally defined as ratings of subjective desire for food or cigarettes (on a 5-point scale) made at the end of each trial. Following previous studies of cue-induced craving, we predicted that craving for cigarettes – but not for food – would increase linearly with self-reported smoking. Following studies of emotion regulation, we predicted that craving for both food and cigarettes would be increased or decreased by the use of cognitive strategies.