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Introduction: The cue reactivity paradigm allows for systematic evaluation of motivational responses to drug-related cues that may elicit drug use. The literature on this topic has grown substantially in recent decades, and the methodology used to study cue reactivity has varied widely across studies. The present research provided a meta-analytic investigation of variables that have an impact on cue reactivity effects to enhance our understanding of this key feature of tobacco use disorders., Methods: A total of 128 publications yielded 249 effect sizes, which were analyzed to investigate the magnitude of the cue reactivity effect and potential moderators., Results: Craving generated a moderate-to-large effect size (Hedges' g = 0.71, p < .001), indicating that drug cues produced significantly greater craving than neutral cues. However, physiological variables yielded significantly lower or nonsignificant effect sizes. Analyses of a variety of empirically and theoretically relevant moderator variables showed that cue modality, cue personalization, cue reactivity environment, and the use of multiple assessments of cue reactivity were significantly associated with the magnitude of cue-specific craving effects (ps < .001). Effect sizes were not significantly related to abstinence status, gender, cigarettes per day, and treatment-seeking status., Conclusions: The results underscored the strength of self-reported craving as an index of cue reactivity across studies, which support theories that posit cue reactivity is core to the addictive process for daily tobacco cigarette smokers. The present research further elucidates the variables that alter the cue reactivity effects across studies and provides recommendations for future cue reactivity research., Implications: A core feature of addiction is that drug-related cues can have a major impact on motivational responses across multiple substance use disorders, including tobacco cigarettes. This paper describes a meta-analysis updating and synthesizing cue reactivity research with tobacco cigarette smokers over the last 20 years, a time of rapid growth for this literature. The study leads to a better understanding of the cue reactivity paradigm across different self-report and physiological variables and identifies factors that may modulate addictive motivation for tobacco cigarettes., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Some evidence suggests that female smokers may show more context-dependent smoking and that males may show more stereotyped smoking (regardless of stress or cue exposure). The goal of this study was to characterize sex differences in response to stressful and smoking cues ecologically presented in daily life and variability in day-to-day smoking behavior., Methods: Adult smokers (N = 177) provided ratings of mood and cigarette craving before and after stress and smoking cues were presented four times daily for 14 days via a mobile device. Linear mixed models tested whether (1) female smokers exhibited greater reactivity to stressful cues than male smokers; (2) pre-cue negative affect increased reactivity to smoking cues more in female smokers than male smokers; (3) across both sexes, greater reactivity to stressful and smoking cues correlated with greater quantity of smoking within a day; and (4) female smokers exhibited greater variability in cigarettes per day (CPD) relative to males., Results: Relative to male smokers, female smokers reported greater negative affect, stress, and craving in response to stressful cues, but not smoking cues, after accounting for time since last cigarette and pre-cue responding. No sex differences in CPD or variability in CPD were detected. Days with higher subjective reactivity to cues were not associated with increased smoking, in either males or females., Conclusions: Sex differences were observed in response to stress but not smoking cues in the natural environment of regular cigarette smokers. Further research is necessary to evaluate whether stress reactivity in female smokers is associated with reduced latency to smoke following stress exposure in daily life., Implications: This study provides naturalistic evidence that female smokers may not be more reactive to smoking cues than males, but experience heightened stress and craving following stress exposure. There was no evidence to support the hypothesis that amount smoked per day varied more for females, relative to males, as a result of more context-driven smoking for females., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Published laboratory studies from the last 50 years that included measures of craving and tobacco-consumption or tobacco-seeking measures were included in a meta-analysis in order to assess the relationship between craving and tobacco use. Seeking measures were further subdivided into those that reflected control by nonautomatic and automatic cognitive processes. Of 2,498 articles identified by the initial literature review, 204 analyses from 50 studies were deemed eligible. Overall, the relationship between craving and outcome behaviors was modest (r = .20, p < .001). Studies that imposed abstinence during data collection showed a stronger relationship between craving and outcome (r = .24, p < .001) than studies that did not (r = .18, p < .001). Further, of those studies that reported dependence, the overall association between craving and outcome was stronger for smokers who were less dependent. Separate meta-analyses revealed that the type of outcome measure moderated the omnibus effect, with the relationship between craving and nonautomatic seeking measures (r = .34, p < .001) being stronger than the relationship between craving and automatic seeking/consumption measures (both rs = 0.15, p < .001). These findings suggest that craving may play a role in, but does not fully account for, tobacco-use behaviors; furthermore, the extent to which craving predicts behavior may be increased when the behavior is under nonautomatic cognitive control.

Background: Cue-reactivity is a robust phenomenon in regular cigarette smokers (Carter and Tiffany, 1999), but it has not been widely investigated in nondependent smokers. Further, most research on cue-specific craving assesses response to cues in a single experimental session. As such, investigations of cue-specific craving have primarily measured state-like but not trait-like responses to smoking stimuli., Methods: This study measured general and cue-specific craving in nondependent smokers and assessed the within-session and cross-session reliability of these two facets of craving. Participants (n=154) attended five laboratory sessions over the course of three months and completed multiple cue-reactivity trials (using smoking and neutral in vivo and photographic stimuli) during each study visit., Results: Results indicated that smoking cues elicited significantly stronger craving than neutral cues across study sessions, and that craving ratings following smoking cues decreased across subsequent sessions. Within-session and cross-session reliability was extremely high., Conclusions: Overall, findings indicate that nondependent smokers experience reactivity to smoking cues, and that this response is quite reliable within and across sessions. Further, the magnitude of cue-specific craving was comparable to what has been observed in heavy, dependent smokers., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Craving is useful in the diagnosis of drug dependence, but it is unclear how various items used to assess craving might influence the diagnostic performance of craving measures. This study determined the diagnostic performance of individual items and item subgroups of the 32-item Questionnaire on Smoking Urges (QSU) as a function of item wording, level of craving intensity, and item stability., Methods: Nondaily and daily smokers (n = 222) completed the QSU on 6 separate occasions, and item responses were averaged across the administrations. Nicotine dependence was assessed with the Wisconsin Inventory of Smoking Dependence Motives. The discriminative performance of the QSU items was evaluated with receiver-operating characteristic curves and area under the curve statistics., Results: Although each of the QSU items and selected subgroups of items significantly discriminated dependent from nondependent smokers, certain item subgroups outperformed others. There was no difference in discriminative performance between use of the specific terms urge and crave or between items assessing intention to smoke relative to those assessing desire to smoke, but there were significant differences in the two major factors represented on the QSU and in craving items reflecting more intense relative to less intense craving. Stability of the item scores was strongly related to the discriminative performance of craving., Conclusions: Items indexing stable, high-intensity aspects of craving that reflect the negative reinforcing effects of smoking will likely be most useful for diagnostic purposes. Future directions and implications are discussed.

Introduction: Craving is often portrayed as a defining feature of addiction, but the role of craving in the addictive process is controversial. Particularly contentious is the extent to which drug craving predicts subsequent relapse., Methods: This review synthesizes findings from 62 smoking cessation studies published through December 2011. Eligible studies measured craving for cigarettes in treatment-seeking smokers and related this to subsequent smoking status. The relationships of general craving and cue-specific craving with treatment outcome were examined separately. Further, analyses that related general craving to smoking status were divided into those that used craving data collected before the quit attempt, after the quit attempt, and those that used change in craving over time as a predictor., Results: Results across studies revealed a total of 198 indices of association with 94 (47%) of these being significant. In general, the findings indicated (a) there were only a few cases of significant associations between craving collected as part of cue-reactivity studies and treatment outcome, (b) postquit craving was a stronger predictor of treatment outcome than prequit craving, and (c) several moderators likely influence the relationship between craving and cessation outcome., Conclusions: The overall results suggest that craving is not a necessary condition of relapse. In addition, inconsistent relationships between craving and treatment outcome call into question the value of craving as a target of treatment and underscore limitations in the prognostic utility of craving.

Smoking cue-exposure research has provided a powerful tool for examining cravings in the laboratory. A key attraction of this method is that tightly controlled experimental procedures can model craving experiences that are presumed to relate to addiction. Despite its appeal, key assumptions underlying the clinical relevance of smoking cue-reactivity studies have been questioned recently. For both conceptual and methodological reasons it may be difficult to tease apart cue-based and abstinence-based cravings. Moreover, conventional cue-reactivity procedures typically generate levels of craving with only minimal clinical relevance. We argue here that sometimes it is unfeasible-and in some instances conceptually misguided-to disentangle abstinence-based and cued components of cigarette cravings. In light of the challenges associated with cue-reactivity research, we offer an alternative approach to smoking cue-exposure experimental research focusing on peak provoked craving (PPC) states. The PPC approach uses nicotine-deprived smokers and focuses on urges during smoking cue-exposure without subtracting out urge ratings during control cue or baseline assessments. This design relies on two factors found in many cue-exposure studies-nicotine deprivation and exposure to explicit smoking cues-which, when combined, can create powerful craving states. The PPC approach retains key aspects of the cue-exposure method, and in many circumstances may be a viable design for studies examining robust laboratory-induced cravings., (© 2012 The Authors, Addiction © 2012 Society for the Study of Addiction.)

Although drug craving has received considerable research attention over the past several decades, to date there has been no systematic review of the general clinical significance of craving. This paper presents an overview of measurement issues of particular relevance to a consideration of use of craving in clinical settings. The paper then considers the relevance of craving across a broad array of clinical domains, including diagnosis, prognostic utility, craving as an outcome measure, and the potential value of craving as a direct target of intervention. The paper is both descriptive and prescriptive, informed by the current state of the science on craving with recommendations for the definition of craving, assessment practices, future research, and clinical applications. We conclude that craving has considerable utility for diagnosis and as a clinical outcome, and that findings from future research will likely expand the clinical potential of the craving construct in the domains of prognosis and craving as a treatment target., (© 2012 New York Academy of Sciences.)

The cue-reactivity paradigm has been used extensively in laboratory settings to study cue-specific craving responses to drug-related cues. However, this procedure has been used in only one study to assess craving in the drug user's natural environment (Warthen & Tiffany, 2009). The present study combined cue-reactivity with ecological momentary assessment (CREMA) to evaluate smokers' cue reactions in natural environments as a further validation and extension of this procedure. A total of 66 daily cigarette smokers carried a personal digital assistant (PDA) and had the opportunity to respond to 32 cue-reactivity sessions across 8 days. Cues were presented through in vivo and photographic modes. During in vivo sessions, participants handled and looked at a cigarette or neutral object, while during photographic sessions, participants looked at a smoking-related or neutral photograph on the PDA. Craving and mood were assessed before and after cue presentations. Cues were also presented in the laboratory both before (Lab I) and after (Lab II) the 8-day CREMA procedure. Participants completed over 90% of cue-reactivity sessions delivered with the CREMA procedure. Analyses revealed robust cue-reactivity in the natural environment and laboratory across both modes of presentation. Photographic cues elicited significantly stronger cue-reactivity effects than in vivo cues across all sessions. The CREMA procedure has been shown to elicit robust cue-reactivity effects across multiple modes of cue presentation. Results support the use of the CREMA procedure for examining cue-specific craving in the natural environment of smokers.

Aims: This experiment was conducted to determine the impact of cigarette deprivation and cigarette availability on reactivity measures to cigarette cues., Participants: Smokers were recruited who were 18 years of age or older, not attempting to quit or cut down on their smoking, smoked at least 20 cigarettes daily, had been smoking regularly for past year and had an expired carbon monoxide level of at least 10 parts per million., Design: Smokers were assigned randomly to abstain from smoking for 24 hours (n = 51) or continue smoking their regular amount (n = 50). Twenty-four hours later, they were exposed to trials of either a lit cigarette or a glass of water with a 0, 50 or 100% probability of being able to sample the cue on each trial. Craving, mood, heart rate, skin conductance, puff topography and latency to access door to sample the cue were measured., Findings: Both exposure to cigarette cues and increasing availability of those cues produced higher levels of craving to smoke. Deprivation produced a generalized increase in craving. There was no consistent evidence, however, that even under conditions of high cigarette availability, deprived smokers were sensitized selectively to presentations of cigarette cues., Conclusions: The data suggest that, even under conditions of immediate cigarette availability, deprivation and cue presentations have independent, additive effects on self-reported craving levels in smokers.

Background: In cigarette smokers, the most commonly reported areas of brain activation during visual cigarette cue exposure are the prefrontal, anterior cingulate, and visual cortices. We sought to determine changes in brain activity in response to cigarette cues when smokers actively resist craving., Methods: Forty-two tobacco-dependent smokers underwent functional magnetic resonance imaging, during which they were presented with videotaped cues. Three cue presentation conditions were tested: cigarette cues with subjects allowing themselves to crave (cigarette cue crave), cigarette cues with the instruction to resist craving (cigarette cue resist), and matched neutral cues., Results: Activation was found in the cigarette cue resist (compared with the cigarette cue crave) condition in the left dorsal anterior cingulate cortex (ACC), posterior cingulate cortex (PCC), and precuneus. Lower magnetic resonance signal for the cigarette cue resist condition was found in the cuneus bilaterally, left lateral occipital gyrus, and right postcentral gyrus. These relative activations and deactivations were more robust when the cigarette cue resist condition was compared with the neutral cue condition., Conclusions: Suppressing craving during cigarette cue exposure involves activation of limbic (and related) brain regions and deactivation of primary sensory and motor cortices.

Background: A recent meta-analysis on cue-reactivity research revealed that cue-specific craving for alcohol is substantially less robust than craving measured for other drugs of abuse. The small effect sizes for alcohol underscore the need for more powerful methods of assessing cue reactivity in humans. The cue-availability paradigm is a modification of the conventional cue-reactivity paradigm and is intended to increase the sensitivity of measuring cue-reactivity to alcohol in humans., Methods: Seventeen non-treatment-seeking alcoholics were tested individually on two different sessions (after priming with alcohol and after priming with placebo-alcohol). Subjects were presented with a total of 32 cue-availability trials. On each trial, subjects were presented with either a target cue (alcohol) or a neutral cue (water). Each cue was available for drinking on 50% of the trials (availability condition). Cue-reactivity measures were self-reports of craving and mood., Results: The alcohol prime had a robust effect on craving. Irrespective of the availability of the cue for consumption or the type of cue, craving was consistently higher when subjects were primed with alcohol than with placebo-alcohol. Negative mood was also higher when it was assessed after the alcohol prime. Negative mood decreased in alcohol-primed subjects when the alcohol cue was available for consumption. The alcohol cue also had a significant, although more modest effect on craving. The alcohol cue consistently elicited higher levels of craving relative to the water cue., Conclusions: These data suggest that the priming effects of alcohol may be a significant factor contributing to the experience of craving and maintenance of drinking. The study also introduces the cue-availability as an additional new method for investigating manipulations of cue-reactivity in alcoholics.

The nature of drug craving and its role in the addictive process is a contentious issue in the addiction sciences. There are numerous disputes regarding the definition, assessment, manipulation and interpretation of craving, and progress toward resolving the enigmas of craving confronts numerous conceptual and methodological challenges. Greater attention to certain fundamental principles of measurement and manipulation should generate immediate and substantial improvements in efforts to understand and control alcohol craving. This paper provides suggestions for enhancing the measurement of self-reported alcohol craving and improving the manipulation of alcohol craving under controlled laboratory conditions. With regard to measurement, single-item scales commonly employed in craving research tend to be handicapped by limited reliability and validity. Multi-item craving scales are more likely to provide the accuracy required to accurately discriminate between different levels of craving across individuals or across different settings. Conceptual and practical considerations for the selection of multi-item craving instruments are discussed. With regard to the manipulation of alcohol craving in the laboratory, recent meta-analyses suggest that alcohol craving effects in such research may be relatively weaker than craving effects found in similar research with other addicts. Therefore, laboratory-based investigations into the nature of alcohol craving should utilize procedures and assessments that are particularly sensitive to the detection of alcohol craving. This paper offers methodological recommendations for enhancing the magnitude of alcohol craving effects generated in laboratory research.

This paper reviews theoretical and methodological issues in the measurement of drug craving, with an emphasis on self-report assessment. Despite the important role that craving plays in many research and clinical settings, the way in which the construct is conceptualized and measured rarely receives sufficient attention. Issues pertinent to conceptualizing craving are identified. Because there is no single perfect measure of craving, it is essential that researchers understand the limitations of each measure. Measurement performance concerns that affect the validity of different measures are reviewed. Non-verbal assessment methods are also reviewed. Research factors that may help determine the optimal measures for a given study are highlighted. It is concluded that advances in assessment will proceed only when combined with additional research and a better theoretical understanding of craving.

Many addiction theories assume that craving plays a central role in the acquisition and maintenance of drug dependence. For example, craving is often depicted as the subjective experience of the motivational state directly responsible for all drinking in the alcoholic. Craving has two prominent features that must be explained by any viable model of craving. First, craving tends to be highly situationally specific, readily triggered by stimuli previously associated with drug use. Secondly, craving can persist well beyond the cessation of drinking in an alcoholic. Conventional theories typically address craving's cue specificity and persistence by invoking concepts of classical conditioning. These theories fall into two classes: those that emphasize withdrawal and those that focus on the positive-incentive properties of drugs. Both types of theories assume that craving processes are represented by the concomitant activation of craving report, drug-seeking and drug use, and specific patterns of autonomic responses. However, research fails to find more than modest relationships across these putative manifestations of craving. The cognitive processing model, described in this paper, offers a different view of craving's form and function and proposes that drug use can operate independently of the processes controlling craving. According to this model, addictive drug use is regulated by automatic cognitive processes, while craving represents the activation of non-automatic processes. These non-automatic processes are activated to either aid in completing interrupted drug use or block automatic drug-use sequences. From this perspective, craving is neither irrelevant nor central to the alcoholic's drug use, but rather serves as a cognitive marker of processes that, only in some instance, may be associated with alcohol seeking and use. The research and treatment implications of this model's assumptions regarding drug use and craving processes are discussed.

Five experts respected for their work in the development of animal models of alcohol craving offer their perspectives in a roundtable discussion format. The panel members discuss the various definitions and theories of alcohol craving and the benefits and limitations of using animal models to study alcohol craving in humans. Animal models have helped further the understanding of craving by providing information about behavior associated with craving. Animal models do have limitations, however. The fact that animals cannot "talk" about their feelings poses difficulties for researchers seeking to map an animal analog of craving onto the human experience.

Traditional models of craving have been based primarily on the concept of classical conditioning. In recent years, however, researchers increasingly have introduced cognitive concepts, such as memory, expectancies, interpretation, and automatic behavior, into their conceptualizations of craving. These efforts have culminated in the development of four cognitive models of craving: cognitive labeling, outcome expectancy, dual-affect, and cognitive processing. The cognitive processing model posits that although many alcohol use behaviors have become automatized processes in the course of an alcoholic's drinking career, craving is a nonautomatic process that requires mental effort and is limited by a person's cognitive capacity. This model also implies that alcohol use and alcohol-seeking behavior can occur in the absence of craving. In addition to introducing various new concepts and models into craving research, the cognitive sciences also offer well-established methodologies for testing these models and analyzing craving processes.

A 32-item questionnaire on smoking urges was administered to 230 daily cigarette smokers assigned to one of three levels of cigarette deprivation (0, 1 or 6 hours). Factor analyses showed that a two-factor solution best described the item structure for each of the three deprivation levels and for the entire sample. Factor scales of 15 and 11 items derived from rotation to simple structure were highly reliable, 0.95 and 0.93, respectively, and moderately correlated (r = 0.71). Average scores on both scales increased significantly with level of deprivation, and the Factor 1 scale was significantly higher than the Factor 2 scale at all levels. Factor 1 scale items reflected primarily intention and desire to smoke, and anticipation of pleasure from smoking. Factor 2 scale items were comprised primarily of anticipation of relief from negative affect and nicotine withdrawal, and urgent and overwhelming desire to smoke.