计量经济分析 = Econometric analysis

The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.

The Self-medication Hypothesis of Substance Use Disorders: A Reconsideration and Recent Applications

Motivational Interviewing: Preparing People for Change

© 2014 The Cochrane Collaboration. Background: There are at least three reasons to believe antidepressants might help in smoking cessation. Firstly, nicotine withdrawal may produce depressive symptoms or precipitate a major depressive episode and antidepressants may relieve these. Secondly, nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect. Finally, some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction. Objectives: The aim of this review is to assess the effect and safety of antidepressant medications to aid long-term smoking cessation. The medications include bupropion; doxepin; fluoxetine; imipramine; lazabemide; moclobemide; nortriptyline; paroxetine; S-Adenosyl-L-Methionine (SAMe); selegiline; sertraline; St. John's wort; tryptophan; venlafaxine; and zimeledine. Search methods: We searched the Cochrane Tobacco Addiction Group Specialised Register which includes reports of trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and PsycINFO, and other reviews and meeting abstracts, in July 2013. Selection criteria: We considered randomized trials comparing antidepressant medications to placebo or an alternative pharmacotherapy for smoking cessation. We also included trials comparing different doses, using pharmacotherapy to prevent relapse or re-initiate smoking cessation or to help smokers reduce cigarette consumption. We excluded trials with less than six months follow-up. Data collection and analysis: We extracted data and assessed risk of bias using standard methodological procedures expected by the Cochrane Collaboration. The main outcome measure was abstinence from smoking after at least six months follow-up in patients smoking at baseline, expressed as a risk ratio (RR). We used the most rigorous definition of abstinence available in each trial, and biochemically validated rates if available. Where appropriate, we performed meta-analysis using a fixed-effect model. Main results: Twenty-four new trials were identified since the 2009 update, bringing the total number of included trials to 90. There were 65 trials of bupropion and ten trials of nortriptyline, with the majority at low or unclear risk of bias. There was high quality evidence that, when used as the sole pharmacotherapy, bupropion significantly increased long-term cessation (44 trials, N = 13,728, risk ratio [RR] 1.62, 95% confidence interval [CI] 1.49 to 1.76). There was moderate quality evidence, limited by a relatively small number of trials and participants, that nortriptyline also significantly increased long-term cessation when used as the sole pharmacotherapy (six trials, N = 975, RR 2.03, 95% CI 1.48 to 2.78). There is insufficient evidence that adding bupropion (12 trials, N = 3487, RR 1.9, 95% CI 0.94 to 1.51) or nortriptyline (4 trials, N = 1644, RR 1.21, 95% CI 0.94 to 1.55) to nicotine replacement therapy (NRT) provides an additional long-term benefit. Based on a limited amount of data from direct comparisons, bupropion and nortriptyline appear to be equally effective and of similar efficacy to NRT (bupropion versus nortriptyline 3 trials, N = 417, RR 1.30, 95% CI 0.93 to 1.82; bupropion versus NRT 8 trials, N = 4096, RR 0.96, 95% CI 0.85 to 1.09; no direct comparisons between nortriptyline and NRT). Pooled results from four trials comparing bupropion to varenicline showed significantly lower quitting with bupropion than with varenicline (N = 1810, RR 0.68, 95% CI 0.56 to 0.83). Meta-analyses did not detect a significant increase in the rate of serious adverse events amongst participants taking bupropion, though the confidence interval only narrowly missed statistical significance (33 trials, N = 9631, RR 1.30, 95% CI 1.00 to 1.69). There is a risk of about 1 in 1000 of seizures associated with bupropion use. Bupropion has been associated with suicide risk, but whether this is causal is unclear. Nortriptyline has the potential for serious side-effects, but none have been seen in the few small trials for smoking cessation. There was no evidence of a significant effect for selective serotonin reuptake inhibitors on their own (RR 0.93, 95% CI 0.71 to 1.22, N = 1594; 2 trials fluoxetine, 1 paroxetine, 1 sertraline) or as an adjunct to NRT (3 trials of fluoxetine, N = 466, RR 0.70, 95% CI 0.64 to 1.82). Significant effects were also not detected for monoamine oxidase inhibitors (RR 1.29, 95% CI 0.93 to 1.79, N = 827; 1 trial moclobemide, 5 selegiline), the atypical antidepressant venlafaxine (1 trial, N = 147, RR 1.22, 95% CI 0.64 to 2.32), the herbal therapy St John's wort (hypericum) (2 trials, N = 261, RR 0.81, 95% CI 0.26 to 2.53), or the dietary supplement SAMe (1 trial, N = 120, RR 0.70, 95% CI 0.24 to 2.07). Authors' conclusions: The antidepressants bupropion and nortriptyline aid long-term smoking cessation. Adverse events with either medication appear to rarely be serious or lead to stopping medication. Evidence suggests that the mode of action of bupropion and nortriptyline is independent of their antidepressant effect and that they are of similar efficacy to nicotine replacement. Evidence also suggests that bupropion is less effective than varenicline, but further research is needed to confirm this finding. Evidence suggests that neither selective serotonin reuptake inhibitors (e.g. fluoxetine) nor monoamine oxidase inhibitors aid cessation.

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Antidepressants for smoking cessation

Given assertions of the theoretical, empirical, and practical importance of self-control, this meta-analytic study sought to review evidence concerning the relationship between dispositional self-control and behavior. The authors provide a brief overview over prominent theories of self-control, identifying implicit assumptions surrounding the effects of self-control that warrant empirical testing. They report the results of a meta-analysis of 102 studies (total N = 32,648) investigating the behavioral effects of self-control using the Self-Control Scale, the Barratt Impulsiveness Scale, and the Low Self-Control Scale. A small to medium positive effect of self-control on behavior was found for the three scales. Only the Self-Control Scale allowed for a fine-grained analysis of conceptual moderators of the self-control behavior relation. Specifically, self-control (measured by the Self-Control Scale) related similarly to the performance of desired behaviors and the inhibition of undesired behaviors, but its effects varied dramatically across life domains (e.g., achievement, adjustment). In addition, the associations between self-control and behavior were significantly stronger for automatic (as compared to controlled) behavior and for imagined (as compared to actual) behavior.

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Taking Stock of Self-Control A Meta-Analysis of How Trait Self-Control Relates to a Wide Range of Behaviors

Although knowledge of the deleterious consequences of cigarette smoking is now widespread, recent estimates indicate that about one in five adults in the United States is a current smoker (Centers for Disease Control, 2005). Reports that the cessation rates observed in clinical trials during the past 2 decades are significantly lower than are those for the 2 preceding decades (Irvin & Brandon, 2000; Irvin, Hendricks, & Brandon, 2003) have led researchers to propose a “hardening hypothesis.” While controversial (Warner & Burns, 2003), this hypothesis posits that those who continue to smoke are more dependent on nicotine and have higher levels of comorbid psychopathology (Hughes & Brandon, 2003). In other words, continuing smokers may possess underlying psychological and biological characteristics that maintain smoking and inhibit cessation.

One such characteristic is impulsivity, which has recently received increasing attention in the literature (e.g., Mitchell, 2004). Previous research has suggested that impulsivity is associated with cigarette smoking (Geist & Hermann, 1990; Jenks, 1992; Kassel, Shiffman, Gnys, Paty, & Zettler-Segal, 1994; Williams, 1973) and that it may inhibit cessation (Doran, Spring, McChargue, Pergadia, & Richmond, 2004). However, mechanisms that may explain this relationship remain largely untested. Additionally, the fact that multiple definitions of impulsivity exist in the literature (Evenden, 1999) renders comparative analysis difficult.

The propensity of more impulsive individuals for substance abuse has often been viewed as an appetitive process. Such individuals are thought to be hypersensitive to reward (Martin & Potts, 2004) and to have difficulty in inhibiting a response to immediately rewarding stimuli (Arnett & Newman, 2000). However, extant evidence also suggests the existence of a negative reinforcement pathway between impulsivity and substance use. For example, Emmons and Diener (1986) have shown that impulsive individuals may experience negative affect more frequently than do others. Additionally, impulsivity appears to be associated with a tendency to use drugs as a response to negative affect. Adolescents with high levels of both impulsivity (defined as acting without forethought) and neuroticism are more likely than are others to drink as a means of coping with negative affect (Cooper, Agocha, & Sheldon, 2000), and teens high in behavioral undercontrol (a temperamental characteristic that reflects lack of premeditation, sensation seeking, and aggression; King & Chassin, 2004) tend to consume more alcohol during bouts of negative affect than do others (Hussong & Chassin, 1994). Individuals with high levels of behavioral undercontrol have also been found to expect (Mann, Chassin, & Sher, 1987) and receive (Sher & Levenson, 1982) greater stress reduction from alcohol consumption than do others.

We recently reported similar findings in smokers. In both studies, impulsivity was assessed with the Barratt Impulsiveness Scale (Patton, Stanford, & Barratt, 1995), which defines impulsivity as a tendency to focus on present rather than future consequences of behavior, a lack of planning, quick decision making, and a tendency to become easily bored or restless. First, in a sample of undergraduate smokers, we found that impulsivity was positively associated with expectations of positive reinforcement and negative affect relief from smoking (Doran, McChargue, & Cohen, 2007). The second study (Doran et al., 2006) suggested that heightened expectations of negative affect relief might be realistic. Following a negative mood induction, participants smoked either a nicotinized or a de-nicotinized cigarette in a repeated-measures design. Higher impulsivity was associated with greater postinduction reduction in self-reported negative affect after smoking a nicotinized cigarette but not after smoking a de-nicotinized cigarette.

Although evidence is somewhat limited, impulsivity has been linked to reactivity to drug cues. The use of the cue reactivity paradigm in substance abuse research is based on the idea that drug-associated environmental stimuli increase susceptibility to drug use (e.g., Baker, Morse, & Sherman, 1987; Marlatt & Gordon, 1985). Impulsivity has been shown to predict craving responses to drug cue exposure in opiate addicts (Powell, Bradley, & Gray, 1992) and heavy drinkers (Kambouropoulos & Staiger, 2001). We recently found that, in the present sample, impulsivity was associated with heightened craving reactivity to a smoking cue (Doran, Spring, & McChargue, 2007).

Although fewer studies have examined affective reactivity to drug cues, cue exposure has been reported to increase negative affect in smokers (Hutchison et al., 1999; Tiffany, Cox, & Elash, 2000). This effect may vary as a function of nicotine deprivation, so that more deprived smokers experience greater postexposure increases in negative affect (Payne, Smith, Sturges, & Holleran, 1996). To the extent that specific affective states trigger smoking, cue-induced affect may be an important contributor to the relationship between cue exposure and subsequent use. Additionally, the impact of cue-induced affect on smoking behavior may be particularly important for impulsive smokers, who may be more prone to substance use during negative affective states.

As Mitchell (2004) has noted, the lack of a standard definition of impulsivity has made integration of the relatively few studies of the relationship between impulsivity and cigarette smoking more difficult. It has been suggested that the term is used to describe several related but distinct phenomena (e.g., disinhibition, difficulty delaying gratification, sensation seeking, lack of persistence) that may have different biological bases (Evenden, 1999). Whiteside and Lynam (2001) recently used factor analysis of several common impulsivity measures to develop the Urgency, Premeditation, Perseverance, and Sensation-Seeking Impulsive Behavior Scale (UPPS), which measures four aspects of impulsivity: urgency (the tendency to act impulsively as a means of reducing negative affect), lack of premeditation, lack of perseverance, and sensation seeking. It is plausible that these facets are distinct characteristics that produce similar behavior (i.e., acting without forethought) under different conditions (Whiteside, Lynam, Miller, & Reynolds, 2005). Although the UPPS was initially developed with an undergraduate sample (Whiteside & Lynam, 2001), it has been shown to differentiate control participants from pathological gamblers as well as from individuals diagnosed with borderline personality disorder and alcohol abuse in a community sample with a mean age of 40.6 years (Whiteside et al., 2005). The use of more comprehensive instruments, such as the UPPS, to assess impulsivity is important for clarification of the relationship between impulsivity and substance abuse. For example, impulsive individuals who tend to use substances to cope with negative affect may have particularly high levels of the urgency facet of impulsivity.

Our primary aim in the present study was to test the hypothesis that more impulsive smokers experience disproportionate changes in negative affect when they are exposed to an environmental smoking cue. To compare the hypothesized negative reinforcement pathway with the traditional conceptualization of substance abuse as an appetitive process among more impulsive individuals, we also assessed positive affect reactivity. Participants were exposed to a smoking cue and to a neutral cue in separate experimental sessions. It was expected that positive and negative affective responses to smoking cue exposure would be strongest among participants who reported low levels of perseverance and high levels of urgency. Individuals low in perseverance tend to have difficulty remaining in aversive situations (e.g., being exposed to a smoking cue but being unable to smoke). For those with high levels of urgency, who may be especially prone to smoking during aversive affective states, smoking cues may be more strongly associated with such states. Consequently, we hypothesized that participants who were low in perseverance and high in urgency would report greater increases in negative affect and greater decreases in positive affect following smoking cue exposure.

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Cue-elicited negative affect in impulsive smokers.

© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.Introduction: Hookah use is increasingly common among U.S. college students, but little is known regarding the relationship between hookah and cigarette use. The purpose of this study was to test the hypothesis that the added nicotine exposure from hookah use may accelerate the uptake of cigarettes. Methods: An ethnically diverse sample of college students (n = 256; 43% female) who had smoked cigarettes in the past month completed 2 in-person interviews over 6 months. This study was a secondary analysis of data collected for a longitudinal study of young adult cigarette smoking patterns. Analyses examined 6-month changes in past 30 day cigarettes smoked and number of days smoking, controlling for age, nicotine dependence, marijuana use, and the respective baseline variable for each outcome. Results: Current hookah use (any use in past 30 days) was endorsed by 34% of participants at baseline, while 94% reported lifetime use. Change in past 30 day number of cigarettes (p = .043) and number of smoking days (p = .040) differed significantly between those who did or did not report recent hookah use at baseline. Hookah users reported a greater number of cigarettes smoked at the 6-month follow-up, while nonusers decreased their smoking quantity. For number of smoking days in the past 30, hookah users reported a smaller decrease than nonusers. Conclusions: Recent hookah use predicted increased cigarette smoking over 6 months in a college sample. These are the first prospective data demonstrating this relationship, indicating the value of developing strategies to prevent hookah use among college students.

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Hookah Use Predicts Cigarette Smoking Progression Among College Smokers

https://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1269&context=psychfacpub

Effect of impulsivity on cardiovascular and subjective reactivity to smoking cues.

Aims: The present study examined the relationship between cigarette smoking and alcohol use outcomes over an 8-year period following treatment for adolescent alcohol and other drug (AOD) use disorders. Methods: The present study was based on a sample of 166 adolescents recruited during inpatient AOD abuse treatment. Included in this study were 123 (74% of the full sample) participants, of whom 41% were female, 81% identified themselves as White and who averaged 15.9 years of age (SD = 1.3) when entering treatment. Data for the present study were drawn from interviews conducted at the time of treatment and 2-, 4-, 6- and 8-years post-treatment. Results: Twenty six percent of participants had quit smoking for > 1 year at the 8-year assessment, while 44% reported persistent smoking over time. Overall smoking rates decreased significantly over time. Subjects associated with the highest alcohol involvement trajectory reported significantly greater likelihood of persistent smoking as well as higher current smoking and cigarette consumption across time points. Conclusions: The significant declines observed in smoking from adolescence into young adulthood were contrary to expectations, indicating that this behaviour may be less stable than previously thought among adolescent AOD abusers. Smoking involvement over time was greater within the highest alcohol use trajectory, consistent with previous evidence for a positive relationship between these behaviours. However, when compared with the general population smoking rates remained very high regardless of alcohol involvement. Thus, individuals treated for AOD abuse as adolescents remained at elevated risk for tobacco related disease regardless of post-treatment AOD use outcomes.

Is cigarette smoking related to alcohol use during the 8 years following treatment for adolescent alcohol and other drug abuse

The present study, a secondary analysis of published data (B. Hitsman et al., 1999), assessed (a) the influence of initial positive mood (PM) on smoking cessation and (b) whether smokers low in PM benefited from fluoxetine versus placebo for cessation. Euthymic adult smokers (N = 103) received 10 weeks of cessation treatment. Analyses showed a Time X PM interaction, indicating that higher baseline PM predicted decreased abstinence during treatment but increased abstinence afterward, mediated by time to dropout. Dichotomous initial PM interacted with drug, suggesting a benefit of fluoxetine for low-PM smokers. Results indicate that lower pretreatment PM may inhibit long-term cessation. Smokers with lower baseline PM may benefit from treatment that increases PM.

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Neal Doran

Papers

Cue-elicited negative affect in impulsive smokers.

Hookah Use Predicts Cigarette Smoking Progression Among College Smokers

Effect of impulsivity on cardiovascular and subjective reactivity to smoking cues.

Is cigarette smoking related to alcohol use during the 8 years following treatment for adolescent alcohol and other drug abuse

Elevated positive mood: a mixed blessing for abstinence.