using ema data to examine negative affect and craving during a quit attempt megan e. piper, ph.d....

Using EMA Data to Examine Negative Affect and Craving

During a Quit Attempt

Megan E. Piper, Ph.D.Assistant ProfessorCenter for Tobacco Research & InterventionDepartment of MedicineUW School of Medicine and Public Health

Research Aims

To examine the patterns of negative affect and craving pre- and post-quit– Withdrawal dimensions include average intensity,

variability/volatility and trajectory (Piasecki et al. 1998; Piasecki et al. 2003a; Piasecki et al. 2000)

To examine how temptation events influence negative affect and craving– Deprivation can enhance cue reactivity, which may

influence smoking motivation (Acri and Grunberg 1992; Gloria et al., 2009; McCarthy et al. 2006; McClernon et al., 2009; Shiffman et al. 2006; Shiffman et al. 1996; Spiga et al. 1994; cf Perkins 2009a)

Research Aims

To examine how withdrawal parameters and reactivity to temptation events are related to short-term cessation success

Recruitment and inclusion/ exclusion criteria

Recruited in Madison and Milwaukee, WI – TV, radio and newspaper advertisements, community flyers– Earned media

Inclusion criteria: – Smoking ≥ 10 cigs/day for the past 6 months – Motivated to quit smoking

Exclusion criteria: – Medications contraindicated for bupropion– Consuming ≥ 6 alcoholic beverages 6-7 days/week– Self-reported history of psychosis or bipolar disorder

CONSORT figure

N = 8526Expressed interest

n = 1418Declined

n = 2010Unreachable

n = 2027Failed screen

n = 3153Passed phone screen

n = 1331Withdrew

n = 1504Randomized

n = 318Excluded

Lozengen = 260

Patchn = 261

Bupropion SR

n = 266

Patch +Lozengen = 267

Bupropion SR + Lozenge

n = 261

Placebon = 189

Study participants

N = 1504 (58.2% women) Ethnicity

– 1258 (83.9%) White – 204 (13.6%) African-American – 42 (2.8%) parents of Hispanic origin

21.9% had a 4-year college degree Mean age = 44.67 (SD = 11.08) Mean cigs. smoked/day = 21.43 (SD = 8.93) Mean number of quit attempts = 5.72 (SD = 9.65)

Weeks

TQD Year 3Year 2Year 16 mo.

V9 V10 V11 V12Infor

mation

Ses

sion

Orienta

tion

V8V7V6V5V4V3 -

Rand

omiza

tion

V2V1

1 2 4 8-1-2-3-4

Baseline Treatment* Follow-up

Study timeline

*Counseling and medication

EMA period

EMA Protocol

Palmtop computers 4 prompts per day

– Waking– 2 random during the day (separated by at least 1

hour)– Prior to going to bed

2 weeks pre-quit and 2 weeks post-quit– Analyzed data 10 days pre-quit and 10 days post-

quit

EMA Questions – Every prompt

In the last 15 minutes rate:– Negative and positive affect– Craving– Hunger– Difficulty Concentrating– Restlessness

Smoking since last prompt

EMA Questions – Every prompt

Self-efficacy Cessation fatigue Motivation to work hard to quit Positive smoking expectancies Temptation events and coping

EMA Questions – Evening Prompt

Cessation medication usage Alcohol and caffeine use Menstruation Stressor occurrence and coping Pleasurable daily activities

EMA Compliance

Of the total 80 assessments (4 times/day for 20 days):– Mean prompts completed = 50.9– Median prompts completed = 53

Missing data was significantly positively related to 8-week relapse – OR = 1.03, p < .001

When analyses controlled for missing data, the results were similar

Mean Negative Affect

Mean Daily Craving

Negative Affect for 4 Participants

Craving for 4 Participants

Temptation

“Since your last report, did anything happen that made you want to smoke?”

Pre-quit (18.9%) vs. Post-quit (19.5%)– Χ2 = 3.69, p = .055

Examine craving and negative affect with a general linear model looking at pre-quit vs. post-quit and temptation event vs. no temptation event

Temptation and Negative Affect

F(1, 63340) = 7.85p = .005

Temptation and Craving

F(1, 63340) = 105.17p < .001

Withdrawal and Cessation

8-week CO-confirmed point-prevalence abstinence

Controlling for treatment and post-quit smoking – Treatment: 0 = placebo, 1 = monotherapy, 2 =

combination therapy – Smoking: 0 = no smoking, 1 = < 1 cig/day, 2 = 1

or more cig/day

Withdrawal and Cessation

Change (post-pre) in: – Mean level– Frequency of extreme reports– Variability (SD)– Mean level when temptation event reported – Mean level when no temptation event reported

Univariate Prediction of 8-week Abstinence – Negative Affect

Withdrawal measure Wald p-value OR OR 95% CIChange in negative affect mean

8.73 .003 .82 .72, .94 

Change in negative affect SD 2.83 .09 .83 .67, 1.03 

Change in percent of negative affect reports greater than 4

1.81 .18 .99 .97, 1.01 

Change in negative affect mean when faced with a temptation event

.92 .34 .95 .86, 1.05 

Change in negative affect mean when not faced with a temptation event

4.77 .03 .85 .74, .98 

Univariate Prediction of 8-week Abstinence – Craving

Withdrawal measure Wald p-value OR OR 95% CI

Change in craving mean 19.58 <.001 .89 .84, .93 

Change in percent of craving reports greater than 7

9.41 .002 .99 .988, .997 

Change in craving mean when faced with a temptation event

6.19 .01 .93 .88, .985 

Change in craving mean when not faced with a temptation event

14.38 <.001 .90 .85, .95 

Best-Fitting Multivariate Model to Predict 8-week Abstinence

Withdrawal measure Wald p-value OR OR 95% CI

Change in craving mean

6.15 .01 .90 .83, .98

Change in negative affect mean

12.92 <.001 .62 .48, .80

Change in negative affect mean when faced with a temptation event

5.43 .02 1.18 1.03, 1.37

Addressing Smoking During EMA

Considerable post-quit smoking is required to reduce withdrawal symptoms (Piasecki et al., 2003)

80% reported smoking <1 cig/day in the first 10 days – 34% reported no smoking

Results were consistent when removed participants who reported smoking 5 or more cigs/day on average for the 10 days post-quit (n = 47)

Conclusions

Relative to negative affect, craving reports are more intense, on average, more variable and are more likely to be extreme– 20% of craving reports were greater than 1 SD– 1.6% of negative affect reports were greater than

1 SD

Craving returns to pre-quit levels by 10 days but negative affect does not

Conclusions

Quitting results in reactivity (i.e., increased negative affect and craving) when confronted with temptation events

Cessation success is related to:– Various withdrawal components: negative affect,

craving and reactivity to temptation events– Various withdrawal parameters: mean level,

extreme reports

Acknowledgements

Piper, M. E., Schlam, T. R., Cook, J. W., Sheffer, M. A., Smith, S. S., Loh, W.-Y., Bolt, D. M., Kim, S.-Y., Kaye, J. T., Hefner, K. R., & Baker, T. B. (2011). Tobacco withdrawal components and their relations with cessation success. Psychopharmacology 216, 569-578. PMCID: PMC3139774

Staff and students at the Center for Tobacco Research and Intervention

NIH grants: P50 DA019706 (NIDA), M01 RR03186 (General Clinical Research Centers Program), 1UL1RR025011 from the Clinical and Translational Science Award (CTSA; Piper), K08DA021311 (Cook), 1K05CA139871 (Baker) and U. S. Army Research Office grant W911NF‑09‑1‑0205 (Loh)

Negative Affect Assessment

PostQuit - Lozenge

I have been TENSE or ANXIOUS.

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Disagree!! Agree!!

PostQuit - Lozenge

I have been TENSE or ANXIOUS.

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Disagree!! Agree!!