Racial Differences in Circadian and Sleep Mechanisms for Nicotine Dependence, Craving, and Withdrawal

The number one preventable cause of death in the world is tobacco use. Cigarette smoking in particular, costs an estimated $300 billion due to expenses related to medical care and lost productivity. Despite similar smoking prevalence rates, blacks suffer disproportionately from smoking-related harms compared to whites.Sleep disparities such as shortened sleep duration, shorter circadian periodicity, earlier chronotype, and increased variability of sleep timing have been reported more frequently in blacks compared to whites. Given that poor sleep quality predicts relapse from smoking cessation programs, particularly among socioeconomically disadvantaged adults, sleep deficiencies and irregular timing of sleep may impact smoking craving and withdrawal symptoms over the course of the 24-hour day. Surprisingly, few studies have examined these temporal patterns of smoking and craving, and none with regard to sleep disruption, chronotype or racial disparities. A better understanding of these factors may explain heterogeneity within the smoking population, especially in minorities. Thus, the purpose of this proposal is to test the central hypothesis that the impact of chronotype and impaired sleep on cigarette usage as well as smoking dependence, urge/craving, and withdrawal depends on race.

Study Overview

• Status: Completed
• Conditions: Smoking; Sleep Disturbance; Nicotine Dependence
• Intervention / Treatment: Behavioral: Sleep restriction condition; Behavioral: Sleep extension condition

Detailed Description

Three specific aims will determine: contributions of sleep timing and sleep quality and quantity to racial disparities in smoking status (Aim 1), objective sleep characteristics and smoking behavior among blacks and whites who smoke cigarettes (Aim 2), and whether sleep restriction modifies craving and withdrawal in racially diverse smokers (Aim 3). Specifically, we will utilize self-report questionnaires, objective measures of sleep quality and timing (actigraphy) and circadian phase (dim light melatonin onset), as well as ecological momentary assessment of cigarette use, smoking urges, cravings, and withdrawal symptoms to identify circadian and sleep characteristics that are most strongly associated with smoking status, heaviness of smoking and dependence among blacks and whites. Finally, we will test whether acute sleep restriction (4 hours of time-in-bed) versus sleep extension (10 hours of time-in-bed) modifies craving and withdrawal symptoms following cessation in black and white smokers. If successful, the results of this study will result in identification of circadian dysfunction and insufficient sleep as mechanisms that underlie the association between sleep and cigarette smoking behaviors and dependence in diverse populations. Moreover, these findings are likely to inform clinicians of the importance of sleep and sleep timing on cigarette smoking behaviors and dependence that will help in the development of novel interventions to reduce morbidity and mortality caused by tobacco use.

• Study Type: Interventional
• Enrollment (Actual): 29
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Alabama
    • Birmingham, Alabama, United States, 35226
      • University of Alabama, Birmingham

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Sub-Study 1

Inclusion Criteria:

1. 18 years or older
2. Able to read and speak English
3. Non-Hispanic African American (Black) or non-Hispanic white race
4. Daily smoker (5 or more cigarettes a day for the past one year and having smoked more than 100 cigarettes in lifetime) or non-smoker (smoked fewer than 100 cigarettes in a lifetime and no smoking-not even a puff- in the last year)

5. Currently residing in Alabama

   Exclusion Criteria:

6. Non-English speaking
7. Lives in restricted environment that does not allow smoking
8. Pregnant or lactating
9. Daily or exclusive use of other tobacco products (e.g., cigars, e-cigarettes) if a smoker; if non-smoker, any other tobacco product use is exclusionary
10. Currently receiving smoking cessation treatment or using electronic cigarettes or other tobacco to try and quit smoking cigarettes
11. Participants would work outside normal 7 a.m. to 6 p.m. hours
12. Former smokers

Sub-study 2

Inclusion Criteria:

1. 18 years or older
2. Able to read and speak English
3. Non-Hispanic African American (Black) or non-Hispanic white race
4. Daily smoker defined as smoking 5 or more cigarettes a day for the past one year and having smoked more than 100 cigarettes in lifetime, as well as by an expired Carbon Monoxide (CO )cut-off of Carbon Monoxide (CO)>10ppm and positive cotinine test to ensure daily smoking OR non-smoker defined as smoking fewer than 100 cigarettes in a lifetime and no smoking-not even a puff- in the last year, as well as by an expired Carbon monoxide (CO) cut-off of Carbon Monoxide (CO)<3 ppm and negative cotinine test.

5. Currently residing in Alabama

   Exclusion Criteria:

6. Non-English speaking
7. Lives in restricted environment that does not allow smoking
8. Pregnant or lactating
9. Testing positive on urine drug screen test at baseline - any drugs other than Tetrahydrocannabinol (THC) not allowed
10. Daily or exclusive use of other tobacco products (e.g., cigars, e-cigarettes) if a smoker; if non-smoker, any other tobacco product use is exclusionary
11. Currently receiving smoking cessation treatment or using electronic cigarettes or other tobacco to try and quit smoking cigarettes
12. Participants would work outside normal 7 a.m. to 6 p.m. hours
13. Former smokers
14. History of a medical condition (e.g., bipolar disorder, migraine, or seizure disorder) that might be exacerbated by sleep deprivation as a result of Study 3
15. History of a serious lung/breathing disease that prevents one from walking or holding their breath for 10 seconds (in order to complete Carbon Monoxide breath test)
16. Cognitive impairment such that participant is unable to provide informed consent
17. Acutely suicidal, manic, acutely intoxicated, or otherwise not stable enough to provide informed consent
18. Living outside of the Birmingham metro area (> 20 miles away from University of Alabama at Birmingham Main Campus)

Sub-study 3

Inclusion Criteria:

1. 18 years or older
2. Able to read and speak English
3. Non-Hispanic African American (Black) or non-Hispanic white race
4. Daily smoker defined as smoking 5 or more cigarettes a day for the past one year and having smoked more than 100 cigarettes in lifetime, as well as by an expired Carbon Monoxide (CO) cut-off of Carbon Monoxide (CO)>10ppm and positive cotinine test to ensure daily smoking

5. Currently residing in Alabama

   Exclusion Criteria:

6. Non-English speaking
7. Lives in restricted environment that does not allow smoking
8. Pregnant or lactating
9. Daily or exclusive use of other tobacco products (e.g., cigars, e-cigarettes) if a smoker; if non-smoker, any other tobacco product use is exclusionary
10. Currently receiving smoking cessation treatment or using electronic cigarettes or other tobacco to try and quit smoking cigarettes
11. Participants would work outside normal 7 a.m. to 6 p.m. hours
12. Former smokers
13. History of a medical condition (e.g., bipolar disorder, migraine, or seizure disorder) that might be exacerbated by sleep deprivation as a result of Study 3
14. Currently taking any psychiatric medications, pain medications (i.e., opioids), or sleep medications (e.g., Ambien, trazodone, melatonin pills, Cannabidiol (CBD) products)
15. History of a serious lung/breathing disease that prevents one from walking or holding their breath for 10 seconds
16. Testing positive on urine drug screen test at baseline - any drugs other than Tetrahydrocannabinol (THC) not allowed
17. Has an apnea-hypopnea index (AHI) score of > 15 on home sleep testing that was conducted during sub-study 2
18. Uses Continuous positive airway pressure (CPAP) machine to sleep at night
19. Cognitive impairment such that participant is unable to provide informed consent
20. Acutely suicidal, manic, acutely intoxicated, or otherwise not stable enough to provide informed consent
21. Living outside of the Birmingham metro area (> 20 miles away from University of Alabama at Birmingham Main Campus)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Sleep Restriction; 4 hours time in bed (1 am to 5 am)	Behavioral: Sleep restriction condition; On day 1, participants will complete study assessments and will be fitted with an Actiwatch and instructed to continue a fixed time in bed (8 hours duration with no more than 20 min deviation) centered on habitual sleep (e.g., 11:00 p.m. to 7:00 a.m.). Naps will not be allowed. Following the one-week baseline sleep stabilization, participants will engage in the sleep restriction condition (4 hours, TIB [Time in Bed]; 1:00 a.m. to 5:00 a.m.). On the day of each sleep study, participants will be admitted to University of Alabama Birmingham (UAB) Highlands Hospital sleep unit at 7:00 p.m. and do an initial CO breathe test and fill out study questionnaires and a timeline follow-back procedure Participants will monitored for smoking withdrawal. Every 2 hours, participants to fill out various questionnaires. Participants will repeat the same conditions as the first night. After a two-week washout, participants will be crossed over to the alternate sleep extension/restriction condition.
Experimental: Sleep Extension; 10 hours time in bed (10 pm to 8 am)	Behavioral: Sleep extension condition; sleep extension On day 1, participants will complete study assessments and will be fitted with an Actiwatch and instructed to continue a fixed time in bed (8 hours duration with no more than 20 min deviation) centered on habitual sleep (e.g., 11:00 p.m. to 7:00 a.m.). Naps will not be allowed. Following the one-week baseline sleep stabilization, participants will engage in the sleep extension condition (10 hours, (TIB); 10:00 p.m. to 8:00 a.m.). On the day of each sleep study, participants will be admitted to University of Alabama Birmingham Highlands Hospital sleep unit at 7:00 p.m. and do an initial CO breathe test and fill out study questionnaires and a timeline follow-back procedure Participants will monitored for smoking withdrawal. Every 2 hours, participants to fill out various questionnaires. Participants will repeat the same conditions as the first night. After a two-week washout, participants will be crossed over to the alternate sleep extension/restriction condition.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Sleep Hygiene Index	A 13-item scale that assesses behaviors, such as variability in wake-time, timing of physical activity, and substance use, that comprise sleep hygiene. Higher values indicate worse sleep hygiene. The minimum value is 0, and the maximum value is 52.	1 day at baseline before either intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pittsburgh Sleep Quality Index	A 7-item self-report measure that assesses global sleep quality over the past month. Additionally, sub-scales that include duration of sleep, sleep disturbance, sleep latency, daytime dysfunction, sleep efficiency, and dependence on hypnotic medication may be calculated from individual items. Higher scores indicate worse sleep quality. The minimum score is 0, and the maximum score is 21.	1 day at baseline before either intervention
Munich Chronotype Questionnaire	Questionnaire that determines chronotype from midsleep time calculated from sleep onset and offset on both free days and work days. Chronotype will be determined from the mid-sleep time on days off. Specifically, Mid-sleep time is equal to Sleep onset + Sleep duration/2. For those who sleep longer on days off than on workdays, we will correct for weekend recovery sleep by subtracting 'sleep debt' accumulated, which is estimated by the following equation: Sleep duration on free days - Sleep duration (average) for the week/2. Chronotype is the participant's midsleep time on free days. Higher values indicate that midsleep time is later in the day. The minimum value is 0, and the maximum value is 24.	1 day at baseline before either intervention
Fagerström Test for Nicotine Dependence	A 6-item self-report measure of nicotine dependence derived from the Fagerström Tolerance Questionnaire. Higher scores indicate greater nicotine dependence. The minimum value is 1, and the maximum value is 10.	1 day at baseline before either intervention
Snoring History, Tired During the Day, Observed Stop Breathing While Sleep, High Blood Pressure, BMI More Than 35 kg/m2, Age More Than 50 Years, Neck Circumference More Than 40 cm and Male Gender (STOP-BANG) Questionnaire	A 8-item self-report questionnaire that assesses the primary risk factors for obstructive sleep apnea to create a total score that ranges from 0 to 8. Higher scores indicate greater risk of sleep apnea.	1 day at baseline before either intervention
Insomnia Severity Index	A 7-item self-report questionnaire that assesses the severity of core symptoms of insomnia over the previous 2 weeks. Higher scores indicate more severe insomnia. The minimum score is 0, and the maximum score is 28.	1 day at baseline before either intervention
Dysfunctional Beliefs and Attitudes About Sleep (DBAS)	A 16-item questionnaire that assesses beliefs about sleep and the consequences of poor sleep. Higher scores indicate more dysfunctional beliefs about sleep. The minimum score is 0, and the maximum score is 10.	1 day at baseline before either intervention
Epworth Sleepiness Scale (ESS)	A 8-item questionnaire that asks individuals to rate their "chances of dozing off" on a scale of 0 (never) to 3 (high) in eight different situations. The scores are summed to create a total score with higher values indicating higher chances of dozing off. The minimum score is 0, and the maximum score is 24.	1 day at baseline before either intervention
Everyday Discrimination Scale (EDS)	This 9-item assessment queries about experiences of discrimination such as being treated less respectfully or people thinking that you are dishonest. Responses range from "almost every day" to "never." Higher score indicate more ways that discrimination was experienced. The minimum score is 0, and the maximum score is 9.	1 day at baseline before either intervention
Perceived Stress Scale - 10 Item (PSS-10)	Self-report questionnaire that assesses a person's perceived stress with a 5-point Likert scale ranging from "Never" to "Very Often." Higher scores indicate greater levels of perceived stress. The minimum score is 0, and the maximum score is 40.	1 day at baseline before either intervention

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Duke- The University of North Carolina at Chapel Hill (UNC) Functional Social Support Questionnaire (FSSQ)	A 8-item 1-5 Likert scale ranging from "much less than I would like" to "as much as I would like" that measures perceived social support. Higher scores indicate greater social support. The minimum score is 1, and the maximum score is 40.	1 day at baseline before either intervention
Patient Health Questionnaire (PHQ-9)	A 9-item instrument that measures severity of depression as well as the presence of suicide ideation. Higher scores indicate more sever symptoms of depression. The minimum score is 0, and the maximum score is 27.	1 day at baseline before either intervention
Generalized Anxiety Disorder (GAD-7)	A 7-item anxiety scale used to identify probable cases of generalized anxiety disorder. Higher scores indicate more severe symptoms of anxiety. The minimum score is 0, and the maximum score is 28.	1 day at baseline before either intervention
Assessing Smoking History	Smoking history will be assessed for daily smokers as smoking 5 or more cigarettes a day for the past one year and having smoked more than 100 cigarettes in lifetime or non-smoker defined as smoking fewer than 100 cigarettes in a lifetime and no smoking-not even a puff- in the last year. Using those definitions, we determined the number of participants who were smokers.	1 day at baseline before either intervention
Brief Wisconsin Inventory of Smoking Dependence Motives (WISDM-37)	The WISDM measures how strongly participants feel 11 potential motivations for smoking. Higher scores indicate being more strongly motivated to smoke. The minimum score is 11, and the maximum score is 77.	1 day at baseline before either intervention
Tobacco Craving Questionnaire-SF (TCQ-SF)	The TCQ-SF contains 12 items to assess participants' craving to smoke cigarettes. Higher scores indicate stronger craving for tobacco. The minimum score is 12, and the maximum score is 84.	1 day at baseline before either intervention
Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)	The ASSIST asks questions assessing level of dependence to 10 different substances. Higher scores indicate more negative impacts of substance use. the minimum score is 0, and the maximum score is 280.	1 day at baseline before either intervention
Minnesota Nicotine Withdrawal Scale (MNWS).	The MNWS is an 8-item measure designed to assess Smokers' cigarette withdrawal in the last 24 hours. Higher scores indicate more severe symptoms of nicotine withdrawal. The minimum score is 0, and the maximum score is 32.	1 day at baseline before either intervention
Alcohol Use Disorders Identification Test-Consumption (AUDIT-C).	A brief 3-item alcohol screening measure that identifies hazardous drinkers or those who have active alcohol use disorders. Higher scores indicate more symptoms of alcohol use disorder. The minimum score is 0, and the maximum score is 12.	1 day at baseline before either intervention
Pain, Enjoyment, General Activity (PEG) Scale	The PEG Scale contains 3 questions regarding how much pain has interfered with enjoyment of life and general activity in the past 7 days. Higher scores indicate greater interference from pain. The minimum score is 0, and the maximum score is 10.	1 day at baseline before either intervention
Trauma History Scale (THS)	The THS is a brief 14-item self-report measure designed to assess traumatic events and how much those events are emotionally bothersome. The scale counts the number of traumas endorsed. The minimum value is 0, and the maximum value is 14.	1 day at baseline before either intervention
PTSD Checklist-Short Form (PCL-5)	The short form of the 20-item PCL-5 which assesses the presence and severity of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD in the past month. The short form contains 4 items. Higher scores indicate more sever symptoms of PTSD. The minimum score is 0, and the maximum score is 16.	1 day at baseline before either intervention
International Consultation on Incontinence Questionnaire-Overactive Bladder	4 items pertaining to overactive bladder symptoms experienced in the past 4 weeks. Higher scores indicate more symptoms of overactive bladder. The minimum score is 0, and the maximum score is 16.	1 day at baseline before either intervention
International Physical Activity Questionnaire (IPAQ)	A set of questionnaires designed to assess physical activity and sedentary lifestyles. The questionnaire measures the minutes of physical activity per week, weighted by the intensity of the activity, referred to as the MET-min. The minimum value is 0, and a value that indicates high levels of activity per week would be 3000.	1 day at baseline before either intervention
Standard Shiftwork Index (SSI)	A battery of self-report questionnaires measuring shift workers' sleep and stress outcomes. We are using the physical health subsections of this questionnaire. The scale counts the number of physical conditions endorsed. The minimum score is 0, and the maximum score is 23.	1 day at baseline before either intervention
Fatigue Severity Scale (FSS)	A 9-item scale measuring severity of fatigue and its effect on participants' activities and lifestyle. Higher scores indicate more severe fatigue. The minimum score is 9, and the maximum score is 63.	1 day at baseline before either intervention
Assessing Continuous Positive Airway Pressure (CPAP) Use	A 5-item survey designed by the research team to assessed whether or not participants are prescribed CPAP, and their adherence to using it. Using that questionnaire, we determined the number of participants who used a CPAP.	1 day at baseline before either intervention

Collaborators and Investigators

• Sponsor: University of Alabama at Birmingham
• Collaborators: National Institute on Drug Abuse (NIDA); University of Oklahoma
• Investigators: Principal Investigator: Karen L Cropsey, Psy.D., University of Alabama at Birmingham

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2021
• Primary Completion (Actual): April 1, 2025
• Study Completion (Actual): April 1, 2025

Study Registration Dates

• First Submitted: May 23, 2019
• First Submitted That Met QC Criteria: May 28, 2019
• First Posted (Actual): May 30, 2019

Study Record Updates

• Last Update Posted (Actual): August 25, 2026
• Last Update Submitted That Met QC Criteria: August 7, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: smoking; Race; socioeconomic disadvantage; sleep deficiencies
• Additional Relevant MeSH Terms: Nervous System Diseases; Mental Disorders; Substance-Related Disorders; Chemically-Induced Disorders; Sleep Wake Disorders; Behavior; Parasomnias; Tobacco Use Disorder; Smoking
• Other Study ID Numbers: 1288803; R01DA046096 (U.S. NIH Grant/Contract)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No