The authors assessed the association between smoking and situational cues, including affect, in real-world contexts. Using ecological momentary assessment, 304 smokers monitored ad-lib smoking for 1 week, recording each cigarette on palm-top computers. Generalized estimating equations contrasted 10,084 smoking and 11,155 nonsmoking situations. After controlling for smoking restrictions, smoking was strongly related to smoking urges and modestly related to consumption of coffee and food, the presence of other smokers, and several activities. Smoking was unrelated to negative or positive affect or to arousal, although it was associated with restlessness. Thus, in daily life, affect appears to exert little influence over ad-lib smoking in heavy smoking adults.

Most attempts to quit smoking end in failure, with many quitters relapsing in the first few days. Responses to smoking-related cues may precipitate relapse. A modified emotional Stroop taskwhich measures the extent to which smoking-related words disrupt performance on a reaction time (RT) task-was used to index the distracting effects of smoking-related cues. Smokers (N = 158) randomized to a high-dose nicotine patch (35 mg) or placebo patch completed the Stroop task on the 1st day of a quit attempt. Smokers using an active patch exhibited less attentional bias, making fewer errors on smoking-related words. Smokers who showed greater attentional bias (slowed RT on the first block of smoking words) were significantly more likely to lapse in the short-term, even when controlling for self-reported urges at the test session. Attentional bias measures may tap an important component of dependence.Keywords attentional bias; emotional Stroop; relapse; smoking cessation Most attempts to quit smoking end in failure. Less than 5% of smokers trying to quit on their own maintain abstinence for 12 months (Hughes et al., 1992;Ward, Klesges, Zbikowski, Bliss, & Garvey, 1997). In smoking-cessation clinics, typically only 20-25% of smokers are abstinent at 6 months, and fewer are abstinent at 12 months. Relapse to smoking is rapid as well as common, with many relapses occurring in the first few days (Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992;Hughes et al., 1992). Medications such as nicotine replacement and bupropion improve outcomes (Jorenby et al., 1999; Silagy, Mant, Fowler, & Lancaster, 2000), but even with treatment, the majority of cessation efforts end in failure. Therefore, it is important to understand the psychological processes that cause the rapid relapse to smoking in the first few days, so that more effective relapse-prevention interventions can be developed.It is unclear what psychological processes underlie early lapses to smoking. Nicotine withdrawal in acute abstinence has been suggested as a critical process enhancing motivation to smoke and lapses to smoking, but it has been hard to demonstrate a strong link between severity of withdrawal and outcome in smoking cessation (Hughes, Higgins, & Hatsukami, 1990;Patten & Martin 1996). Many theories of drug addiction assume that responses to drugrelated cues are critical in maintaining drug use (e.g., Niaura et al., 1988;Robinson & Berridge, 1993;Siegel, 1983;Stewart, de Wit, & Eikelbloom, 1984;Wikler, 1948). Research on the details of initial lapse episodes (e.g., Shiffman, Paty, Gnys, Kassel, & Hickcox, 1996) suggests that environmental stimuli and events play a substantial role in precipitating initial lapses, and when such a lapse occurs, complete relapse is nearly certain to follow: 85-90% of lapses lead NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript to relapse (e.g., Kenford et al., 1994). There have also been reports of associations between measures of cue reactivity and clinical outcome (Abrams, Monti, Carey, Pinto...

Smokers (N = 3,030) were randomized to receive 1 of 3 interventions: (a) a self-help quit kit, (b) a quit kit plus 1 telephone counseling session, or (c) a quit kit plus up to 6 telephone counseling sessions, scheduled according to relapse probability. Both counseling groups achieved significantly higher abstinence rates than the self-help group. The rates for having quit for at least 12 months by intention to treat were 5.4% for self-help, 7.5% for single counseling, and 9.9% for multiple counseling. The 12-month continuous abstinence rates for those who made a quit attempt were 14.7% for self-help, 19.8% for single counseling, and 26.7% for multiple counseling. A dose-response relation was observed, as multiple sessions produced significantly higher abstinence rates than a single session. The first week after quitting seems to be the critical period for intervention.Telephone counseling has attracted increasing interest as an alternative system for delivery of services in the field of smoking cessation (e.g., Anderson, Duffy, Hallet, & Marcus, 1992;Curry, McBride, Louie, Grothaus, & Wagner, 1992;DeBusk et al., 1994; Lando, Hellerstedt, Pirie, & McGovern, 1992;Orleans et al., 1991;Ossip-Klein et al., 1991;Prochaska, DiClemente, Velicer, & Rossi, 1993;Shiffman, Read, Maltese, Rapkin, & Jarvik, 1985). From the smoker's standpoint, its main attractions are accessibility and convenience. There are no transportation difficulties and fewer scheduling conflicts than in most other cessation programs. Also, receiving counseling in the privacy of one's home provides treatment access to individuals who might not normally seek "counseling" to quit smoking. These factors encourage smokers to use the service (Zhu etal., 1995 cantly increases the success rate (e.g., Orleans et al., 1991;Ossip-Klein et al., 1991), others report only a short-term effect, with the long-term outlook no better than that of selfhelp(e.g., Curry etal., 1992; Lando etal., 1992). Those studies that have shown a significant intervention effect for telephone counseling, however, did not include a randomized design to test for a dose-response relation between the number of sessions and the treatment effect.The present study examined the effects of two levels of telephone counseling and compared them with the effects of a selfhelp approach. The lower intensity counseling consisted of one session before quitting. The higher intensity counseling included the same pre-quit session plus up to five sessions after the smoker had quit. We tested two hypotheses: (a) that counseling would produce a higher abstinence rate than a self-help quit kit, and (b) that multiple sessions of counseling would produce a higher abstinence rate than a single session.

According to social learning models of drug relapse, decreases in abstinence self-efficacy (ASE) and increases in positive smoking outcome expectancies (POEs) should foreshadow lapses and relapse. In this study, the authors examined this hypothesis by using ecological momentary assessment data from 305 smokers who achieved initial abstinence from smoking and monitored their smoking and their ASE and POEs by using palmtop computers. Daily ASE and POEs predicted the occurrence of a 1st lapse on the following day. Following a lapse, variations in daily ASE predicted the onset of relapse, even after controlling for concurrent smoking. ASE and POEs generally neither mediated nor moderated each other's effects. These data emphasize the role of dynamic factors in the relapse process.

It is clear that nicotine dependence is a driving motive behind tobacco use and cigarette smoking (U.S. Department of Health and Human Services, 1988). Nevertheless, deeper understanding of motivation for smoking continues to propel theoretical speculation and empirical research. In particular, a notable feature of the nicotine-dependence or nicotine-regulation model is that it does not readily account for the situational variability in smoking. Researchers have focused on the immediate motives or triggers for smoking, in part because falling nicotine blood levels, per se, which would dictate regularly spaced smoking, do not seem to adequately explain variations in daily smoking rate and timing (Hatsukami, Morgan, Pickens, & Champagne, 1990;Pomerleau & Pomerleau, 1987). Some evidence suggests that smoking follows discemable pattems and is particularly likely to occur in certain situations or Saul Shiffman has undertaken research and consultancy for manufacturers of smoking cessation products, including nicotine replacement products and bupropion, and at the time this chapter was written was consulting exclusively for Glaxo-SmithKline. Saul Shiffman and Jean A. Paty are also founders of invivodata, inc., which provides electtonic diaries for clinical trials. This research was supported by Grant DA06084 from the National Institute on Drug Abuse. We are grateful to David Abrams and Michael Sayette for providing usefiil comments on a draft of this chapter.