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Tapper,K.(2018).Mindfulnessandcraving:effectsandmechanisms.ClinicalPsychology

Review,59,101-117.

Mindfulnessandcraving:effectsandmechanisms

KatyTapper

City,UniversityofLondon

PsychologyDepartment

SchoolofSocialSciences

CityUniversityLondon

WhiskinStreet

London

EC1R0JD

UK

Katy.tapper.1@city.ac.uk

Tel:+44(0)2070408500

Fax:+44(0)2070408887

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Abstract

Mindfulnessmeditationhasalongtraditionofbeingusedtomanagecravings.This

paperreviews30experimentalstudiesthathaveexaminedtheeffectsofdifferenttypes

ofmindfulnesspracticeoncravingsforfood,cigarettesandalcohol.Thefindingsare

interpretedinlightofrelevanttheoriesofcraving.Thestudiesshowmostsupportfor

theelaboratedintrusiontheoryofdesireandconditioningmodels.Theysuggestthat

whilstmindfulnessstrategiesmaybringaboutimmediatereductionsincraving,such

effectsarelikelytostemfromworkingmemoryload,andwillnotnecessarilybe

superiortoalternativestrategiesthatalsoloadworkingmemory.Likewise,reductions

incravingoverthemediumtermmayoccurduetoextinctionprocessesthatresultfrom

theindividualinhibitingcraving-relatedresponses.Again,alternativestrategiesthat

promoteresponsesuppressionmaybeequallyeffective.Nevertheless,asmaller

numberofstudiesshowpromisingresultswheremindfulnessexerciseshavebeen

repeatedlypracticedoveralongerperiodoftime.Theresultsofthesestudiesprovide

tentativesupportforBuddhistmodelsofcravingthatsuggestmindfulnesspracticemay

conferuniquebenefitsintermsofbothcravingreductionandreducingtheextentto

whichcravingleadstoconsumption.Furtherresearchwouldbeneededtoconfirmthis.

Keywords

mindfulness;craving;food;cigarettes;alcohol;behaviorchange

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Mindfulnessandcraving:effectsandmechanisms

Cravingcanbedefinedasanintense,consciousdesire,usuallytoconsumea

specificdrugorfood(Drummond,2001;May,Kavanagh&Andrade,2015;Tiffany&

Wray,2012;Pelchat,2002).Althoughtheclinicalrelevanceofcravinghasbeen

questioned(Wray,Gass&Tiffany,2013),thereisalsoasignificantbodyofresearchthat

suggestsitiscausallylinkedtobehavior.Forexample,cravingpredictsrelapseepisodes

insubstanceuse(Serre,Fatseas,Swendsen&Auriacombe,2015)andfoodcravings

predictbotheatingandweightgain(Boswell&Kober,2016).Assuch,cravingsare

oftenconsideredanappropriatetargetforintervention,theassumptionbeingthat

reducingcraving,orchangingaperson’sresponsetocraving,willimpactuponthe

relatedbehavior.

Mindfulnessmeditationhasalongtraditionofbeingusedtoaddresscravings.

AccordingtoancientBuddhisttexts,cravingleadstosufferingbutcanbeavoided

throughmindfulnessmeditationpractice(DhammacakkappavattanaSutta:Settingin

MotiontheWheelofTruth[SN56.11],2013).Morerecently,mindfulness-based

interventionshavebeenusedtoexplicitlytargetcravingswiththeaimofbringingabout

clinicallyrelevantchangestobehavior(e.g.,Alberts,Mulkens,Smeets&Thewissen,

2010;Ruscio,Muench,Brede&Waters,2016;Zemestani&Ottaviani,2016).However,

suchinterventionsoftencomprisearangeofmindfulnessandnon-mindfulness

components,makingitdifficulttounequivocallyattributeanychangesincravingtothe

mindfulness-basedelementsoftheintervention(e.g.,Bowenetal.,2009;Brickeretal.,

2014;Garland,Robert-Lewis,Tronnier,Graves&Kelly,2016;Zemestani&Ottaviani,

2016;seealsoTapper,2017).Assuch,theeffectsofmindfulnesspracticeoncraving

haveyettobescientificallyestablished.

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Mindfulnessinterventionsalsotypicallyemployarangeofdifferenttypesof

strategy,forexampletheymayincludeexercisesdesignedtopromotegreater

awarenessofbodilysensations,todevelopanattitudeofacceptancetoward

uncomfortablefeelings,ortohelpindividualsseethemselvesasseparatefromtheir

thoughtsandemotions(Tapper,2017).However,wecurrentlyhavelimited

understandingofthewaysinwhichthesedifferenttypesofstrategymayinfluence

craving-relatedoutcomes,eitherindependently,orincombination.Althoughsome

authorshaveproposedmodelstoaccountforpotentialeffects(Breweretal.,2013),

manyaspectsofthesehaveyettobetestedexperimentally.Assuchwelackafull

understandingofthewaysinwhichmindfulnesspracticemightinfluencecravings.This

isimportantbecauseasoundtheoreticalbasisisessentialforthedevelopmentof

effectiveinterventions(Michie&Abraham,2004).

Thecurrentarticleaimstoaddresstheselimitationsbyreviewingstudiesthat

haveexaminedtheindependenteffectsofmindfulnessoncraving.Inotherwords,the

reviewisrestrictedtostudiesinwhichtheexperimentalmanipulationorintervention

consistsonlyofmindfulnesscomponents.Suchanapproachinevitablyexcludes

interventionsthatcombinemindfulnessstrategieswithothertherapeuticapproaches1

1Anumberofexistingreviewsalreadyexaminetheeffectsofthesetypesofmulti-

componentmindfulness-basedinterventionsinareasrelevanttocraving,including

substanceusedisorders(Chiesa&Serretti,2014;Zgierskaetal.,2009),substance

misuse(Li,Howard,Garland,McGovern&Lazar,2017),smokingcessation(Maglioneet

al.,2017),bingeeating,emotionaleatingandweightloss(Katterman,Kleinman,Hood,

Nackers&Corsica,2014;Olson&Emery,2015;O’Reilly,Cook,Spruijt-Metz&Black,

2014).

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(e.g.,Mindfulness-OrientedRecoveryEnhancement,seeGarland,2013;Acceptanceand

CommitmentTherapy,seeHayes,Strosahl&Wilson,1999).However,restrictingthe

reviewinthiswayshouldallowanyeffectsoncravingtobemoreconfidentlyattributed

tothemindfulnessmanipulation.Itshouldalsomakeiteasiertocomparetheeffectsof

differenttypesofmindfulnesspracticeaswellasevaluatepotentialmechanismsof

action.Assuch,thereviewhasthreekeyaims:(a)toexaminetheeffectsofmindfulness-

basedpracticesoncraving,(b)tocomparetheeffectsofdifferenttypesofmindfulness-

basedpracticesoncraving,and(c)toexplorethemechanismsviawhichmindfulness-

basedpracticesmayexertanyeffectsoncraving.

Thereviewisinformedbyconceptualizationsofmindfulnessthatdistinguish

betweenthreekeycomponents;presentmomentawareness,acceptanceand

decentering(Creswell,2017;Tapper,2017).Presentmomentawarenessreferstothe

self-regulationofattentionsothatitismaintainedonpresentmomentexperience,for

exampleonesbreath,bodilysensationsorthecontentofonesthoughts;acceptance

involvestakinganon-judgmentalattitudetowardsonesthoughts,feelingsandbodily

sensations;decenteringmeansviewingonesthoughtsandfeelingsastransientevents

thatareseparatetooneself.Inpracticeitmaybedifficulttocompletelydistinguish

betweentheeffectsofthesethreedifferenttechniquessinceacceptanceand

decenteringlikelyrequireacertainamountofpresentmomentawareness.Itisalso

possiblethatacceptanceanddecenteringarisespontaneouslyfromrepeatedpresent

momentawareness(Bishopetal.,2004;Brown&Ryan,2004;Shapiro,Carlson,Astin&

Freedman,2006).Nevertheless,itispossibletotargetthesetechniquesindependently

anddifferenttheoriesofcravingmakedifferentialpredictionsabouttheirrelative

importance.Forthisreason,thecurrentreviewisguidedbytheemphasiseachstudy

placesoneachofthesethreedifferentcomponents.

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Thereviewbeginsbylookingatthewaysinwhichmindfulnessrelatesto

selectedtheoriesofcraving,inordertoidentifypotentialmechanismsofactionand

specificpredictionsthatcanbeexperimentallytested.Itthenexaminesstudiesof

mindfulnessandcravinginlightofthesetheorieswithaviewtoidentifyingfuture

directionsformoreexperimentalworkintheareaaswellasinformingthedevelopment

ofmoreevidence-basedmindfulnessinterventionsdesignedtotacklecravings.

TheoriesofCraving

Awiderangeofdifferenttheoriesandmodelshavebeenputforwardtoaccount

forcravings(seeSkinner&Aubin,2010).Afulldiscussionoftheseisbeyondthescope

ofthecurrentarticle;onlythosewithrelevancetothepotentialimpactofmindfulness

practiceoncravingwillbeconsideredhere.Thesearegroupedunderthebroad

headingsofconditioning-basedmodels,cognitivemodels,andBuddhistmodels.

Conditioning-basedmodels.Conditioning-basedmodelsdrawonclassicalor

Pavlovianconditioning.Theystatethatcuesthatpredicteitherdruguseitself,or

withdrawalfromadrugcancometoelicitphysiologicalresponsesthatoccurduetouse

ofthedrug,orinhomeostaticresponsetotheuseofthedrug.Theseinturnresultina

feelingofcraving(Skinner&Aubin,2010).Suchmodelshavealsobeenappliedtofood

cravings(Jansen,Havermans&Nederkoorn,2011).Forexample,ifapersonalways

stopsforadoughnutontheirwaytowork,cuesassociatedwithtraveltoworkmay

eventuallycometoelicitinsulinandsalivaryresponses.Accordingtoconditioning-

basedmodels,thesewillbeexperiencedbytheindividualasacravingandtheywillbe

morelikelytoeat.Whereacueisassociatedwithdruguse,oreating,preventingthe

behavioralresponsewilleventuallyextinguishtheassociationwiththecue.Inother

words,thecuewillnolongerpredictdruguseoreatingandthereforewillnolonger

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elicitthephysiologicalresponseandtheexperienceofcraving.Accordingtosuch

models,cravingscouldalsobereducedbysimplyavoidingthecuesthatelicitthem.

Thusintermsofmindfulness,anystrategythatpromotesexposuretorelevant

cuesintheabsenceofthebehavioralresponsewill,accordingtosuchmodels,reduce

boththefrequencyandstrengthofcravingsthroughextinction.Thiscouldapplyto

acceptancestrategiesinwhichtheindividualisencouragedtoacceptuncomfortable

thoughtsandfeelingsratherthantrytoavoidorcontrolthem.Althoughsuchastrategy

wouldnothaveanyeffectoncravingsintheshortterm,wemayseeareductionovera

longertimeperiodifthetechniqueisconsistentlyappliedandprovidedtheindividual

managestosuccessfullyinhibitthebehavioralresponse.Iftheindividualisunableto

suppressthebehaviorwewouldnotexpecttoseeanychangeinlevelofcraving.

However,itisunclearwhetherthistechniquewouldbeanymoresuccessfulcompared

tootherprogramsormotivationalstrategiesthatpromoteresponsesuppression(e.g.

Jansenetal.,2011).Onewayinwhichitmightbemoreeffectiveisifitleadsto

increasedexposuretoconditionedstimuli.Forexample,iftheindividualisencouraged

toacceptcravingsratherthantrytoavoidthem,theymaybemorewillingtomaintain

exposuretorelevantcues.Thisinturnwouldleadtomorerapidextinction,again

assumingtheindividualisabletoresistthetargetsubstance.Thesametypeofeffects

mayalsoapplytopresentmomentawarenesstechniquesthatdirecttheindividual’s

attentiontorelevantcues(whichmaybeinternal,suchasnegativemood,aswellas

external);providingthebehavioralresponseisinhibited,increasedexposuremaylead

tomorerapidextinctionandhencetoarelativelyfasterreductioninthefrequencyand

strengthofcravings.

Onepotentialdifficultywiththistypeofstrategyinrelationtofoodcravings,is

thatindividualsneedtoeat.Thismeansthatitmaybedifficulttoconsistentlyinhibit

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eatinginresponsetoaparticularcue.Forexample,ifoneisapplyinganacceptance

strategytochocolatecravingsingeneral,butisaimingtoreduce,ratherthanquiteating

chocolate,effectsoncravingsmaybemorelimitedsinceontheoccasionswhen

chocolateiseaten,associationsbetweencues(e.g.thesightofchocolate)andeatingwill

inevitablybestrengthened.Acceptanceandpresentmomentawarenessstrategiesmay

bemoresuccessfulatreducingcravingswheretheyareusedtotargetaveryspecific

cue-responseassociation,andwheretheindividualispreparedtocompletelyquitthat

specificresponse,suchaseatingachocolatebarduringamid-morningcoffeebreak.

Nevertheless,evenwheresuchstrategiesareappliedmoregenerally,iftheindividual

successfullymanagestoinhibittheireating,thismayincreaseself-efficacyinrelationto

resistingcravings.Sinceself-efficacyisanimportantdeterminantofbehaviorchange

(Bandura,1998;Teixeiraetal.,2015)thismayhelppromotereducedconsumption.

Underthesecircumstanceswemayseechangesineatingbehaviorintheabsenceofany

changeincravings.Indeed,thereissomeevidencetosupportthistypeofdecoupling

effectinresearchonsmoking,amongparticipantswhohavesimplycutbackon

smokingratherthanabstainedcompletely(Bowen&Marlatt,2009;Elwafi,Witkiewitz,

Mallik,Thornhill&Brewer,2013,seealsoLevin,Luoma&Haeger,2015).

Cognitivemodels.Whilstcognitivemodelsofcravingmayincludereferenceto

conditioningprocesses,theydifferfromconditioningmodelsinthattheyalsoassume

thathigherordercognitiveprocesses,suchasattentionandmemoryplayanimportant

roleinthecravingresponse.Thethreecognitivemodelswithmostrelevancefor

mindfulnesspracticearethecognitiveprocessingmodel(Tiffany,1990;Tiffany&

Conklin,2000),theelaboratedintrusiontheoryofdesire(Kavanagh,Andrade&May,

2005;May,Andrade,Kavanagh&Hethrington,2012;Mayetal.,2015),andthetheoryof

groundedcognition(Barsalou,2008).Thesewilleachbeconsideredinturn.

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Cognitiveprocessingmodel.Thecognitiveprocessingmodel(Tiffany,1990;

Tiffany&Conklin,2000)wasdevelopedtoaccountfordrugaddiction.Itstatesthatin

theaddict,druguseiscontrolledbyactionplansthatarestoredinmemoryandcarried

outinanautomaticmanner.Accordingtothistheory,episodesofcravingonlyarise

whensomethinginterruptstheexecutionofthisactionplan,preventingtheindividual

fromconsumingthedrug.Thismayoccurbecauseofanexternalevent,suchasthedrug

beingunavailable,orasaresultoftheindividual’sinternaleffortstoabstainfromthe

drug.

Accordingtothistheory,episodesofcravingarenotcausallyrelatedtodruguse

orrelapseandthereforeeffortstoreducecravingareunlikelytoimpactupondruguse

behavior.Instead,thetheorysuggeststhatinterventioneffortsshouldbefocusedon(a)

removingthestimulithatelicittheactionplans,or(b)protectingorenhancingthe

processingresourcesthatareneededtoinhibittheexecutionoftheactionplan(Tiffany

&Conklin,2000).Mindfulness-basedpresentmomentawarenesstechniquesare

relevantforthistheorybecauseoftheiremphasisonbecomingawareofwhatis

happeningatthatmomentintime,inotherwordsbringingconsciousawarenessto

whatmightotherwisebeautomaticprocessesandbehaviors.Thusforanindividual

whoismotivatedtoabstainfromdrugs,increasedpresentmomentawarenessmayhelp

betterenablethemtorecognizewhentheyareabouttoautomaticallyconsumeadrug

whichwouldinturnallowthemtoinhibittheaction;inotherwords,mindfulnessmay

increaseaperson’sabilitytoregulateautomaticbehaviours.However,althoughthis

mightleadtoareductionindrugusebehaviorwewouldexpectthistobecoupledwith

anincreasedfrequencyinepisodesofcraving.

Elaboratedintrusiontheoryofdesire.Theelaboratedintrusion(EI)theoryof

desire(Kavanaghetal.,2005;May,Andrade,Kavanaghetal.,2012;Mayetal.,2015)

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emphasizestheroleofcognitiveprocessesintheexperienceandmaintenanceof

episodesofcraving.Inkeepingwithconditioningmodels,itmaintainsthattheinitial

sourceofcravingsarelearnedassociationsbetweenspecificinternalorexternalcues

andaparticularbehavior(e.g.eating).These,togetherwithassociatedphysiological

responses,mayresultinintrusivethoughts.Whenthesethoughtselicitpowerful

affectivereactions,orasenseofdeficit,theyleadtocognitiveelaboration.Cognitive

elaborationisacontrolledprocessinwhichrelevantinformationissoughtfrom

memorythenmanipulatedinworkingmemoryinordertoconstructvividsensory

imagesrelatedtotheobjectofdesireanditsacquisition.AccordingtoEItheory,itisthis

cognitiveelaborationthatisexperiencedasdesireorcravingand,becauseofthe

similaritybetweenmentalimageryandrealcues,italsoservestomaintainand

augmentcraving.Thusaccordingtothismodel,anythingthatpreventsorinterruptsthe

elaborativeprocesseswillservetopreventorlimitthedurationofthecravingepisode.

Intermsofmindfulnesstechniques,bothpresentmomentawarenessand

decenteringstrategiesmayservethisfunction.Attendingtopresentmoment

experiencemaymeanthatattentionalprocessesaredirectedtowardarangeof

differentsensoryinputs,ratherthaninternalimageconstruction.Thismaypreventthe

elaborationofintrusivethoughts,andthuspreventcravingfromoccurring.Oritmay

interruptacravingepisode,restrictingitsduration.Aswithconditioning-basedmodels

ofcraving,ifthistechniqueisrepeatedlypracticed,withthebehavioralresponse

repeatedlysuppressed,associationsbetweencuesandtherelevantbehaviorwillbe

extinguishedsuchthattherewillbefewerintrusivethoughts,andareductioninthe

frequencyofcravingepisodes.Thetechniqueofdecenteringmayhaveasimilareffect;

encouragingapersontoseetheirthoughtsassimplythoughtsmayinterrupttheir

elaboration.Forexample,ifthoughtsaboutthepleasurablesmellofcigarettesmokeare

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followedbyanawarenessofthisassimplya‘thought’,thismaybemorelikelytobe

followedbythoughtsaboutabstinence-relatedgoals,ratherthanthoughtsaboutthe

satisfyingeffectsofsmokingacigarette(Tapper&Ahmed,2015).However,itisnot

clearthatthesestrategiesofpresentmomentawarenessanddecenteringwould

necessarilybemoresuccessfulthanothertechniquesthatpreventorinterrupt

elaboration,suchasdivertingattentionorengagingintasksthatloadworkingmemory

(e.g.Kemps&Tiggemann,2007;2013;VanDillen,Papies&Hofmann,2013).

Intermsofacceptancestrategies,accordingtoEItheory,itispossiblethatthey

mayactuallyexacerbatecravings;ifanindividualis,intheabsenceofanyother

instruction,encouragedtoaccepttheirthoughtsandfeelings,thismayresultinthem

engaginginmoreelaboration,whichmayinturnincreaseboththestrengthand

durationofthecravingepisode.

NegativeaffectalsoplaysanimportantroleinEItheory;byincreasingthe

individual’ssenseofdeficititincreasesthelikelihoodthatintrusivethoughtswillbe

elaborated.Thereisevidencetosuggestthatmindfulnesscanimproveemotional

regulationanddecreasenegativeaffect(Chambers,Gullone&Allen,2009).Arangeof

differentmechanismshavebeenputforwardtoexplainthiseffect,includingreduced

rumination(Williams,2008),reducedreactivitytopotentiallyemotivestimuli

(Chambersetal.,2009),exposureandextinctionprocesses(Hölzeletal.,2011)and

positivereappraisal(Garland,Gaylord&Park,2009;Hölzeletal.,2011).Assuch,

reductionsinnegativeaffectrepresentsanadditionalpathwayviawhichmindfulness

strategiesmayreducethefrequencyanddurationofcravingepisodes.However,such

processesareunlikelytobecapturedinalaboratorysetting.

Additionally,presentmomentawarenessexercisestypicallyinvolveattention

regulation.Continuedmindfulnesspracticemaythereforeresultinimprovementsin

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attentionregulation(Chiesa,Calati&Serretti,2011;Mrazek,Franklin,Phillips,Baird&

Schooler,2013).ConsistentwithEItheory,thisimprovedattentionregulationcould

impactuponcravingviaanumberofdifferentpathways.First,thereissomeevidenceto

suggestthatmindfulnesspracticemayhelpreduceattentionalbiastowardsubstance-

relatedstimuli(Garland,Boettiger,Gaylord,Chanon&Howard,2012;Garland&

Howard,2013),presumablybyenhancingattentionaldisengagement(Garland,

Froeliger&Howard,2014).Researchsuggeststhat,inkeepingwithEItheory,

attentionalbiasandcravinghavereciprocaleffectsononeanother,suchthat

attentionalbiascanincreasecravingandincreasesincravingcanalsoleadto

attentionalbias(Field&Cox,2008;Fieldetal.,2016).Assuch,ifmindfulnesspractice

canimproveattentionaldisengagement,andindoingsoleadtoreductionsin

attentionalbias,itshouldalsoresultinreducedcravingfrequency.

Asimilarprocesscouldalsocomeintoeffectafteracravingepisodehasbeen

initiatedsinceimprovedattentionaldisengagementcouldenhancetheindividual’s

abilitytodiverttheirattentionawayfromelaborativeprocessesinvolvedinthe

constructionofsensoryimages.Assuchwemayseereductionsinthedurationof

cravingepisodes.

Finally,thetwoprocessesoutlinedabove(divertingattentionawayfromstimuli

thatelicitcraving,anddivertingattentionawayfromelaborativeprocessesinvolvedin

themaintenanceofcraving)couldalsobeappliedtostimuliandruminationassociated

withnegativeaffect.Assuch,improvedattentionregulationcouldalsoreducecraving

viaareductioninnegativeaffect,asdetailedpreviously.

Thus,accordingtoEItheory,mindfulnesspracticecouldhelplimitthefrequency

anddurationofcravingepisodesviaimprovementsinattentionregulation.However,

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wewouldonlyexpectsucheffectstooccurafteracertainperiodofrepeated

mindfulnesspractice.

Theoryofgroundedcognition.Thefinalcognitivetheorythatwillbe

consideredhereisthetheoryofgroundedcognition(Barsalou,2008).Accordingtothis

theory,individualsdrawonpreviousexperiencetosimulateinteractingwithstimuli

theyencounterintheirenvironment,andthesestimulatesimilarareasofthebrainto

realinteractions,triggeringassociatedbodilyresponses,increasingbothconscious

desireandappetitivebehaviorsoutsideofconsciousawareness(Papies&Barsalou,

2015).Accordingtothistheory,applyingthemindfulnesstechniqueofdecentering,

shouldhelpreducethebelievabilityofthesementalsimulations,andindoingsoreduce

theextenttowhichtheyelicitdesire.Assuchweshouldseeimmediateeffectsonthe

strengthofcravingepisodes.Again,wherethesearecoupledwithsuppressionofthe

behavioralresponse,weshouldalsoeventuallyseereducedcravingfrequency,dueto

extinctionprocesses.

Buddhist-basedmodels.Severalacademicshaveproposedmodelsofcraving

anddesirederivedfromtraditionalBuddhistaccounts(Breweretal.,2013;Grabovac,

Lau&Willett,2011).Interestingly,thesearesimilartoEItheoryinthatcravingis

conceptualizedasacognitiveresponsetoautomatic,conditionedassociations.

AccordingtoBuddhisttexts,perceptualstimuliorthoughtsresultinautomaticaffective

reactions,basedonourpreviousexperiencewiththose,orrelatedstimuli.These

affectivereactionsleadtomentalelaborationandafeelingofdesire(orcraving),either

tomaintainpositivefeelingsoravoidnegativefeelings.Thisfeelingofdesiremotivates

aparticularbehavioralresponse.Wherethisbehaviorisreinforced(i.e.through

maintenanceoravoidanceofpositiveornegativefeelingsrespectively),ahabitmay

starttoemerge(Breweretal.,2013;Grabovacetal.,2011).Forexampleif,uponvisiting

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anewbar,wesampledandenjoyedanexoticliqueur,onournextvisitthesightsand

soundsofthebarmayelicitafeelingofpleasureassociatedwiththetasteoftheliqueur.

Thisfeelingofpleasuremayleadtoadesiretomaintainthispleasure.Thedesire

comprisesboththoughtsandemotionsandisexperiencedasacraving.Thecraving

leadsustoorderaglassoftheliqueur,whichisenjoyableandsoreinforcesthe

behaviorofdrinkingliqueurinthisparticularbarinordertomaintainafeelingof

pleasure.Withrepetitionwemaygetintothehabitofalwaysdrinkingthisparticular

liqueurinthisparticularbar.

Accordingtothisaccountthereareseveralwaysinwhichmindfulnesspractice

influencescravings.First,similartoEItheory,Buddhist-basedmodelsstatethatan

individualcanonlymaintainattentionononeobjectatatime.Thusincreasingpresent

momentawarenessofperceptualstimuli,and/orouraffectivereactiontothese,will

preventthesubsequentthoughtsandreactionsthatconstitutecraving(Grabovacetal.,

2011).Assuch,weshouldseeareductioninthefrequencyanddurationofepisodesof

craving.AccordingtoGrabovacetal.(2011),anattitudeofacceptancefacilitatesthe

individual’sabilitytomaintaintheirattentionontheirpresentmomentexperienceasit

helpspreventnegativethoughtssuchasself-judgment.Assuchwewouldnotexpect

acceptancestrategiesalonetoinfluencecravingbutwewouldexpectacceptanceplus

presentmomentawarenesstoreducethefrequencyanddurationofcravingepisodesto

agreaterextentthanjustpresentmomentawareness.

Additionally,Buddhist-basedmodelssuggestthatbymorecloselyobserving

theiraffectivereactions,theindividualdevelopsaninsightintotheircauses,their

transientnatureandthefutilityofattemptingtosustainoravoidthem.Thisincreased

metacognitiveawarenessmotivatestheindividualtoavoidactingontheircravings

(Breweretal.,2011;Grabovacetal.,2011).Assuch,whereanindividual’scraving

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relatedbehaviorisatoddswiththeirgoals,wewouldexpecttoseeadecoupling

betweencravingandbehavior,withepisodesofcravingnolongerpredicting

consumption.Eventually,becausecravingisnolongerbeingreinforced,wewouldalso

expecttoseeareductionincravingfrequencyandstrength.

Summaryofkeypredictionsbasedonmodelsofcraving

Table1providesasummaryofkeypredictedeffectsofdifferentmindfulnessstrategies

oncravingaccordingtothemodelsdescribedabove.

Table1.

Keypredictedeffectsofpresentmomentawareness,acceptanceanddecenteringstrategies

oncravingfrequency,strengthanddurationovertheshort,mediumandlongterm

accordingtodifferentmodelsofcraving.

Mindfulnessstrategy

Relativepointatwhicheffectshouldappear

Typeofeffectoncraving

Model(s)thatpredictsuchan

effectPresentmomentawareness

Immediate Reducedfrequencyandduration

EI;Buddhist

Mediumterm Increasedfrequency(whereindividualismotivatedtoinhibitcraving-relatedbehavior)

Cognitiveprocessing

Mediumterm Decouplingoftherelationshipbetweencravingandcraving-relatedbehavior

Buddhist

Mediumtolongterm

Reducedfrequencyandstrength(wherecraving–relatedbehaviorisconsistentlysuppressed)

Conditioning;EI,Buddhist

Mediumtolongterm

Reducedfrequencyandduration(viaimprovedattentionregulation)

EI

Acceptance Immediate Increasedstrengthandduration

EI

Immediate Reducedfrequencyandduration(whenemployedwithpresentmomentawareness)

Buddhist

Mediumtolong Reducedfrequencyand Conditioning

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term strength(wherecraving-relatedbehaviorisconsistentlysuppressed)

Mediumtolongterm

Reducedfrequencyandstrength(whenemployedwithpresentmomentawarenessandwherecraving-relatedbehaviorisconsistentlysuppressed)

Buddhist

Decentering Immediate Reducedfrequencyandduration

EI

Immediate

Reducedstrength Groundedcognition

Mediumtolongterm

Reducedfrequencyandstrength(wherecraving-relatedbehaviorisconsistentlysuppressed)

EI

Mediumtolongterm

Decouplingoftherelationshipbetweencravingandcraving-relatedbehavior

Buddhist

Table1illustratesthewaysinwhichdifferentmodelsmakedifferentpredictions.For

example,EItheoryandBuddhistmodelsaretheonlyonesthatpredictimmediate

reductionsincravingasaresultofincreasedpresentmomentawareness,thecognitive

processingmodelistheonlyonetopredictincreasedcravingasaresultofpresent

momentawareness,andEItheoryistheonlyonethatpredictsimmediateincreasesin

cravingasaresultofacceptancestrategies.Likewise,Buddhistmodelsaretheonly

modelstoexplicitlypredictadecouplingbetweencravingandcraving-relatedbehavior

andEItheoryandgroundedcognitionareuniqueinpredictingimmediatereductionsin

cravingasaresultofdecentering.Thenextsectionreviewsrelevantstudieson

mindfulnessandcravinginlightofthesepredictions.

EffectsofMindfulnessonCraving

Literaturesearchandstudyselection.AliteraturesearchofEnglishlanguage

publicationswasconductedduringMay2016usingWebofScienceandthesearch

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terms‘mindful*’,‘attentiveeating’and‘intuitiveeating’,eachpairedwiththeterms

‘craving’,‘desire’and‘urge’.ThissearchwasrepeatedinMay2017andSeptember2017

toidentifyanyadditionalpublications.Thesesearchesledtotheidentificationof294

records.Thetitlesandabstractsofthesewerereviewedand250wereexcludedonthe

basisofatleastoneofthefollowing:(a)nomindfulnessmanipulation,(b)nocontrolor

comparisongroup,(c)nocravingordesirerelatedoutcome,(d)anon-ingestivecraving

ordesirerelatedoutcome(e.g.sexualdesireorgambling),(e)meetingabstract

providinglimitedinformation.Theremaining44paperswereexaminedinfull.Ofthese,

27wereexcludedonthegroundsthatthey(a)combinedmindfulnesswithnon-

mindfulnesstechniques,(b)didnotincludeacravingrelatedoutcome,(c)hadno

controlorcomparisongroupand/or(d)reportedsecondaryanalysisofdataalready

includedinthereview.Afurthersixpaperswereidentifiedfromthereferencesections

ofthesepublicationsandalsoexaminedinfull.Twooftheseweresubsequently

excludedforhavingnocravingrelatedoutcomeandexaminingnon-ingestiverelated

craving.Anadditionalfivepaperswereidentifiedonthebasisofauthorknowledge.

Thisresultedinatotalof26publications,describing30studies,16ofwhich

examinedfood-relatedcravings,11cravingsforcigarettes,andthreecravingsfor

alcohol.ThekeyfeaturesofthesestudiesaresummarizedinAppendixA.Theyare

orderedaccordingtothetimeperiodoverwhichcravingswereassessed.Unless

otherwisestated,measuresofcravinganddesireprimarilyrefertostrengthofcraving

whilstmeasuresof‘traitcraving’includeassessmentsofstrength,frequencyand

duration.

Immediateeffects.Atotalof21studiesincludedmeasuresofcravingtaken

eitherduringorimmediatelyfollowingthemindfulnessmanipulation(seeAppendixA).

Withinthese21studiestherewereatotalof44comparisons;14showedsignificantly

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lowerlevelsofcravinginthemindfulnessconditioncomparedtoacontrolcondition

(Caselli,Gemelli,Spada&Wells,2016;Cropley,Ussher&Charitou,2007;Hamilton,

Fawson,May,Andrade&Kavanagh,2013;May,Andrade,Willoughby&Brown,2012;

Schumacher,Kemps&Tiggemann,2017;Ussher,Cropley,Playle&Mohidin,2009;

Westbrooketal.,2013),oneshowedatrendinthisdirection(Papies,Pronk,Keesman&

Barsalou,2015),22showednodifference(Adamsetal.,2013;Alberts,Thewissen&

Middelweerd,2013;Archetal,2016;Bowen&Marlatt,2009;Fisher,Lattimore&

Malinowski,2016;Hamiltonetal.,2013;May,Andrade,Batey,Berry&Kavanagh,2010;

Murphy&MacKilop,2014;Schumacheretal.,2017;Szasz,Szentagotai&Hofmann,

2012;Ussheretal.,2009;Vincietal.,2014),sixshowedahigherlevelofcravinginthe

mindfulnesscondition(Albertsetal.,2013;Archetal.,2016;Mayetal.,2010;Murphy&

MacKilop,2014;Szaszetal.,2012;Vincietal.,2014;),andoneshowedatrendinthis

direction(Archetal.,2016).Thus,takentogether,theseresultsfailtoprovide

compellingevidenceforanimmediatebeneficialeffectofmindfulnessoncraving.

However,giventhediversityofmindfulnessstrategiesandcomparisonconditions

employedinthesestudies,itisworthexaminingthemmoreclosely.

Ofthe15comparisonsthatshowedsignificantornearsignificantbenefitsof

mindfulness,fiveemployedpresentmomentawareness(Cropleyetal.,2007;Hamilton

etal.,2013;May,Andrade,Willoughbyetal.,2012;Ussheretal.,2009),oneemployed

bothpresentmomentawarenessandacceptance(Westbrooketal.,2013)andnineused

decentering(Casellietal.,2016;Papiesetal.,2015;Schumacheretal.,2017).However,

thecontrolconditionsin12ofthese15comparisonscomprisedlisteningto(asopposed

todecenteringfrom)apre-recordedaudioofalcoholrelatedthoughts(Casellietal.,

2016),listeningtoanaudiorecordingofanaturalhistorytext(Cropleyetal.,2007;

Ussheretal.,2009),nostrategy(Westbrooketal.,2013),mindwandering(Hamiltonet

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al.,2013;May,Andrade,Willoughbyetal.,2012;Schumacheretal.,2017)andviewing

picturesoffoodinarelaxedmanner(asopposedtodecenteringfromreactionstothem;

Papiesetal.,2015).Thus,arguably,thesestudiesmaynothavecontrolledforthe

additionalworkingmemoryloadthemindfulnessstrategieslikelyentailed.Asnoted

previously,accordingtoEItheoryanystrategythatengagesworkingmemory,

particularlythevisuospatialsketchpad,willpreventtheelaborationofintrusive

thoughtsandindoingsoreducecravings.Assuchwecannotbecertainthatthe

mindfulnessstrategiesbroughtaboutreductionsincravingoverandabovewhatmight

havebeenachievedwithotherstrategiesthatplacedanequivalentloadonworking

memory,forexamplevisualizationstrategies.

Outofthe44comparisons,14specificallyusedcontrolconditionsthatarelikely

tohavedrawnonvisualworkingmemory,throughtheuseofguidedimagery,imagery

diversion,wordpuzzlesandisometricexercises(Archetal.,2016;Fisheretal.,2016;

Hamiltonetal.,2013;Mayetal.,2010;Schumacheretal.,2017;Ussheretal.,2009).Of

these14comparisonsninefoundnodifferencebetweenthemindfulnessandcontrol

conditions(Archetal.,2016;Hamiltonetal.,2013;Mayetal.,2010;Schumacheretal.,

2017;Ussheretal.,2009),threefoundlowerlevelsofcravinginthemindfulness

condition(Schumacheretal.,2017),onefoundhigherlevelsofcravinginthe

mindfulnesscondition(Archetal.,2016),andonefoundatrendinthisdirection(Arch

etal.,2016).Thethreecomparisonsthatfoundlowerlevelsofcravinginthe

mindfulnessconditionusedadecenteringtechnique(Schumacheretal.,2017).These

findingssupportthetheoryofgroundedcognitionthatpredictsthatdecenteringwill

havebeneficialeffectsoverandaboveguidedimagery.However,areplicationofthis

studyfailedtoshowanysignificantdifferencesbetweenthesetwoconditions

(Schumacheretal.,2017).Thestudiesthatusedpresentmomentawarenesstechniques

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(Archetal.,2016;Fisheretal.,2016;Hamiltonetal.,2013;Mayetal.,2010;Ussheret

al.,2009)allfoundnodifferenceincraving,orhigherlevelsinthemindfulness

condition.TheseresultsareconsistentwithEItheoryinthattheysuggestthatpresent

momentawarenessdoesnotleadtoimmediatereductionsincravingsoverandabove

whatcanbeachievedviaothertechniquesthatalsopreventtheelaborationofcraving-

relatedthoughts.

Afurtherthreestudiesusedlisteningtoaudioasacontrolcondition,eithera

naturalhistorytext(Cropleyetal.,2007;Ussheretal.,2009),oradescriptionofa

rainforest(Fisheretal.,2016).Onemightexpectthesetoeffectivelypreventthe

elaborationofcraving-relatedthoughtsonlyinsofarastheyincludedvisualimageryand

engagedparticipants’attention.Wherepresentmomentawarenesswascomparedto

thedescriptionofarainforestitshowednorelativereductionsincravingontwo

separateoccasions(Fisheretal.,2016);whereitwascomparedtolisteningtoanaudio

recordingofanaturalhistorytext,bothstudiesshowedgreaterreductionsincravingin

thepresentmomentawarenesscondition(Cropleyetal.2007;Ussheretal.,2009).

Arguablyhowever,thenaturalhistorytextemployedinthelattertwostudies(Natural

HistoryandAntiquitiesofSelborne,firstpublishedin1789)maynothavefullyengaged

theparticipants’attentionortheirvisualworkingmemory.

Intermsofthetypesofmindfulnessstrategiesemployedacrossthese21studies,

16involvedsometypeofpresentmomentawareness,forexampleofbodilysensations,

cravingsorthesensorypropertiesoffood.Justonestudy(Szaszetal.,2012)attempted

tomanipulateacceptanceinisolationandthisshowednosignificanteffectoncravings

comparedtothosewhoengagedinthoughtsuppression,andincreasedcravings

comparedtothosewhoengagedinreappraisal.Fourstudiesmanipulateddecentering

inisolation(Casellietal.,2016;Papiesetal.,2015;Schumacheretal.,2017).Asnoted

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previously,whilstoneofthesestudies(Schumacheretal.,2017)showedbeneficial

effectsofdecenteringoverandaboveguidedimagery,thiseffectwasnotreplicatedina

secondstudy(Schumacheretal.,2017).Alsoasnotedpreviously,althoughtwoother

studiesalsoshowedlowercravingsinthemindfulnesscondition(Casellietal.,2016;

Papiesetal.,2015),itispossiblethattheeffectsweredrivenbyworkingmemoryload

ratherthanthedecenteringstrategyperse.Furtherresearchwouldbeneededto

explorethisinterpretationaswellasestablishanyimmediatebenefitsofdecentering

overandaboveguidedimagery.

Thusintermsofrelevanttheoriesofcravings,identifiedinTable1,theresults

arebroadlyconsistentwithEItheory;wherepresentmomentawarenessand

decenteringstrategieshavebroughtaboutimmediatereductionsincraving,thismaybe

becausetheyentailedagreaterloadonworkingmemorythatinterruptedelaborative

processes;wherepresentmomentawarenessstrategieshavebeencomparedtoother

strategiesthatalsoengageworkingmemory,theylosetheiradvantage.Additionally,

consistentwithEItheory,theonlystudytoattempttoexamineacceptanceinisolation,

foundthatitincreasedcravingsrelativetoareappraisalstrategy(Szaszetal.,2012).

Theothertwotheoriesthatrelatetotheimmediateeffectsofmindfulnessare

groundedcognitionandBuddhistmodels.Groundedcognitionpredictsthatdecentering

strategieswouldproduceimmediatereductionsincraving,andwhilstthreestudies

haveshownsucheffects(Casellietal.,2017;Papiesetal.,2015;Schumacheretal.,

2017),asmentionedpreviouslyonlyoneofthesestudiescompareddecenteringwith

guidedimageryandtheadvantageofdecenteringwasnotreplicatedinasecondstudy

(Schumacheretal.,2017).Assuch,furtherresearchwouldbeneededtotestthis

predictionanddistinguishbetweenanEIversusgroundedcognitionaccountof

decenteringeffects.Likewise,itisdifficulttodrawanyfirmconclusionsaboutBuddhist

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modelsfromthesestudies.Buddhistmodelswouldpredictimmediatereductionsin

cravingasaresultofpresentmomentawarenessstrategies,withacceptanceenhancing

theseeffects.Althoughsucheffectsarenotsupportedbythestudiesreviewedhere,itis

importanttonotethatinnoneofthesestudiesdidparticipantsreceivemindfulness

training;theywereinsteadsimplyprovidedwithbriefinstructiontohelpthememploy

aspecifictechnique.Itispossiblethatsuchtechniquescanonlybeemployedeffectively

withacertainamountofpractice.Assuchonecouldarguethattheseparticularstudies

arenotagoodtestofBuddhistmodelsofcraving.Furtherresearchlookingatthe

immediateeffectsofpresentmomentawarenessstrategies,amongindividualswho

havereceivedsometraininginthistechnique,wouldbeamoreappropriatetest.

Latereffects:within24hours.Twelvestudiesincludedmeasuresofcraving

takenatleast5minutesafterthemanipulation,butwithin24hours.Ofthesetwelve

studies,oneshowedsignificantbeneficialeffectsofthemindfulnessstrategy

(Schumacheretal.,2017),fiveshowednosignificanteffectsofthemindfulnessstrategy

(Bowen&Marlatt,2009;Fisheretal.,2016;May,Andrade,Willoughbyetal.,2012;May

etal.,2010),fourshowedamixofsignificantbeneficialeffectsandnon-significant

effects(Cropleyetal.,2007;Ussheretal.,2009;Nosen&Woody,2013;Schumacheret

al.,2017)andtwoshowedamixofsignificantdetrimentaleffectsandnon-significant

effects(Albertsetal.,2013;Szaszetal.,2012).Thusonceagain,takentogether,the

overallevidenceforaneffectofmindfulnessoncravingisnotverycompelling.

Ofthefivestudiesthatfoundsignificantbeneficialeffects,twoarethose

discussedpreviouslythatcomparedapresentmomentawarenessstrategywith

listeningtoanaudiorecordingofanaturalhistorytext(Cropleyetal.,2007;Ussheret

al.,2009).Assuchonecannotruleoutthepossibilitythatthemindfulnessmanipulation

exerteditseffectsimplybyloadingworkingmemory.Nevertheless,thesestudies

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provideausefulinsightintothetimecourseofsucheffects;inoneofthesestudies,

reducedcigarettecravingextendedto5minutesafterthemanipulation,buthad

disappearedby10minutes(Cropleyetal.,2007),whilstintheotherstudyreduced

cigarettecravinginside(butnotoutside)thelaboratorywasstillmaintainedwhen

assessed30minutesafterthemanipulation(Ussheretal.,2009).Thesefindingscould

beinterpretedasindicatingthatstrategiesthatinterrupttheelaborationofcraving-

relatedthoughtsmayhavebenefitsthatextendbeyondthepointatwhichtheyare

implemented.Thiscouldbeduetoareductioninthelikelihoodofcraving-related

intrusivethoughtsafterthemindhasbeenoccupiedwithunrelatedsubjectmatter.This

interpretationwouldbeconsistentwiththefactthateffectsweremoreshort-lived

outsidethelaboratory(Ussheretal.,2009)whereonewouldexpectparticipantstobe

exposedtoagreaternumberofcuesthatwouldelicitsmoking-relatedintrusive

thoughts.

Twoofthestudiesthatfoundsignificantbeneficialeffectsarealsothose

discussedpreviouslythatcompareddecenteringwithbothguidedimageryandmind

wanderingconditions(Schumacheretal.,2017).Inoneofthesestudiesthedecentering

strategymaintainedreducedlevelsofcravingintensity10minutesafterthe

manipulation,relativetobothmindwanderingandguidedimageryconditions.Inthe

secondstudythedecenteringstrategywasonlysuperiortothemindwandering

condition.

Thefifthstudythatfoundbeneficialeffectsformindfulness(Nosen&Woody,

2013)compared60-90minuteinstructioninpresentmomentawarenessand

acceptanceofcigarettecravingswiththeprovisionofstandardpsycho-educational

materialornotreatment.Eightassessmentofsmokingurgeswerethenmadeacrossthe

courseof1-dayperiodofadlibsmokinganda1-dayperiodthatcoincidedwithaquit

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attempt.Whilsttherewerenosignificantdifferencesincravingsbetweenthethree

groupsduringtheperiodofadlibsmoking,duringthequitattemptthepatternof

cravingsacrossthecourseofthedayvariedsuchthatduringtheevening,smoking

urgesweresignificantlyloweramongthoseinthemindfulnessgroupcomparedtoboth

thoseinthepsycho-educationalgroupandnotreatmentcontrol;butonlyamongst

participantswhosuccessfullymanagedtoabstainfromsmoking(n=122).Whenthose

whohadfailedtoabstainwereincludedintheanalysis(n=153),thesedifferences

disappeared.

TheseresultsareconsistentwithEI,conditioningandBuddhistmodelsof

cravingthatpredictthatwhereacraving-relatedbehaviorissuccessfullysuppressed,

cravingsmaysubsidemorerapidlywherepresentmomentawarenessandacceptance

strategiesareemployed,duetotheincreasedcontactwithconditionedstimulithat

presentmomentawarenessandacceptanceentail.However,itisimportanttonotethat

thisstudywasconductedwithsmokerswhowereattemptingtoquitsmoking;these

theorieswouldpredictthatsucheffectswouldbelesslikelytooccurforbehaviorsthat

onecannotcompletelyquit,forexampleasmayoccurinrelationtofoodrelated

cravings.Futureresearchwouldalsobeneededtoestablishwhetheramindfulness-

basedinterventionmaybemorelikelytoleadtorelapse,particularlyintheearlypartof

theintervention.

Again,themajorityofthetwelvestudiesthattookmeasuresofcravingwithina

24-hourperiodusedeitherpresentmomentawarenessoracombinationofpresent

momentawarenessandacceptance.Onlytwostudiesexamineddecentering

(Schumacheretal.,2017)andonlyonestudy(Szaszetal.,2012)attemptedtoexamine

acceptanceinisolation;thislatterstudyfoundincreasedcravingsrelativetoa

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reappraisalstrategyandnosignificantdifferenceincravingswhencomparedtoa

suppressionstrategy.

Thusagain,thesestudiesareconsistentwithEItheory,andconditioningmodels

ofcraving.Thereissometentativesupportforthetheoryofgroundedcognitionbut

furtherresearchwouldbeneededtoconfirmthis.Therearenostudieswithinthis

groupthattestspecificpredictionsmadebycognitiveprocessingtheory.

Latereffects:after24hours.Elevenstudiesincludedmeasuresofcraving

takenlaterthan24hoursaftertheinitialmanipulationorinterventiondelivery(see

AppendixA).Thetimeframeoverwhichthesemeasuresweretakenrangedfrom3

daysto7weeks.Ofthese11studies,threefoundsignificantreductionsincravinginthe

mindfulnessgroup(Albertsetal.,2010;Davis,Manley,Goldberg,Smith&Jorenby,

2014;Tang,Tang&Posner,2013),twofoundamixtureofsignificantandnon-

significantreductionsinthemindfulnessgroup(Lacaille,Zacchia,Bourkas,Glaser&

Knauper,2014;Ruscio,Muench,Brede&Waters,2016),fivefoundnosignificant

differences(Bowen&Marlatt,2009;Forman,Hoffman,Juarascio,Butryn&Herbert,

2013;Moffitt,Brinkworth,Noakes&Mohr,2012;Murphy&MacKilop,2014;Nosen&

Woody,2013;)andonefoundatrendtowardshighercravinginthemindfulnessgroup

(Hooper,Sanoz,Ashton,Clarke&McHugh,2012).However,ifwelookatthepatternof

significantandnon-significanteffectsaccordingtothetimeframeoverwhichcravingis

observed,aclearerrelationshipbeginstoemerge.Thethreestudiesshowingsignificant

reductionsinthemindfulnessgroupassessedcravingoverthelongestdurations:7

weeks(Albertsetal.,2010),6weeks(Davisetal.,2014),and2weeks(Tangetal.,

2013).Thesixstudiesshowingnosignificantdifferences,oratrendtowardhigher

cravinginthemindfulnessgroup,assessedcravingovertheshortestdurations,ranging

fromthreedays(Formanetal.,2013)tosevendays(Bowen&Marlatt,2009;Moffittet

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al.,2012;Murphy&MacKilop,2014).Thetwostudiesthatfoundamixtureofsignificant

andnon-significanteffectsassessedcravingovera2-weekperiod(Lacailleetal.,2014;

Ruscioetal.,2016).

Thereareseveralpossibleexplanationsforthispatternofresults;itmaybethat

thosestudiesthatwerecarriedoutoveralongertimeframeemployedhigherintensity

interventionsthatledtoparticipantsmoreeffectivelyimplementingthemindfulness

techniques.Similarly,participantsmayhaveacquiredtheseskillsonlyafteramore

extendedperiodofpractice.Alternatively,consistentwithconditioning,EIandBuddhist

modelsofcraving,itmaybethateffectsonlystarttoemergeafteracertainperiodof

practice.

Itisdifficulttoclearlydistinguishbetweenthesethreepossibilitiesonthebasis

ofthestudiesreportedinAppendixA.Thethreestudiesshowingsignificanteffects

includedthemostintensivemindfulnesspractice,equivalentto5hours(Tangetal.,

2013),morethan24hours(Davisetal.,2013)ora7-weekmanualthatparticipants

workedtheirwaythrough(Albertsetal.,2010).Bycontrast,inthestudiesthatfound

nosignificanteffects,instructionrangedfromwhatisdescribedas‘brief’(Murphy&

MacKilop,2014),to5-10minutes(Hooperetal.,2012),to2hours(Formanetal.,2013).

Additionally,allthestudiesthatreportedsignificantreductionsincravingonatleast

onemeasureaskedparticipantstorepeatedlypracticethetechniqueonadailybasisas

wellasapplythetechniqueeachtimetheyhadacraving.Thistypeofspecific

instructiontorepeatedlypracticethetechniqueisgenerallynotreportedinthose

studiesthatdidnotfindanysignificanteffects.Thusthosestudiesthatdidfind

significanteffectsarenotonlymorelikelytohaveassessedcravingoveralonger

timeframe,theyarealsomorelikelytohaveincludedmoremindfulnesspracticeandto

haveensuredparticipantswererepeatedlypracticingthesetechniquesonadailybasis.

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Onlyonestudy(Ruscioetal.,2016)tooklongitudinalmeasuresofcraving

allowingfortheassessmentofchangeovertime.Thisshowednoeffectofmindfulness

practiceonlevelsofcravingassessedatrandomtimesthroughouttheday.Cravings

assessedimmediatelyfollowinga20-minutemindfulnessmeditation,versusasham

meditation,weresignificantlylower,butthiseffectdidnotchangeovertime.Assuch,

andgiventhattheshammeditationincludedinstructionsto‘gobacktolettingyour

mindwanderfreely’,theeffectscouldbeexplainedbyworkingmemoryload.However,

thetimeframeforthisstudywasrestrictedtojust2weekssomaynothavebeen

sufficientforothereffectstoemerge.

Similarly,theotherstudiesthatshowedsignificanteffectsoncravingdidnot

necessarilycontrolfortheeffectsofworkingmemoryload.Asdiscussedpreviously,

accordingtoEItheory,anystrategythatloadsvisualworkingmemoryshouldreduce

craving.Lacailleetal.(2014)comparedmindfulnessstrategiestorecitingthealphabet

thenmultiplesof2suntil100,whichisunlikelytoinvolvesignificantamountsofvisual

workingmemory.LikewiseDavisetal.(2014)andAlbertsetal.(2010)compared

mindfulness-basedinterventionstostandardalternatives.Whilstthesewouldhelp

controlforimportantvariablessuchashaloeffectsandsocialsupport,theyareunlikely

tohaveincludedstrategiesthatloadedvisualworkingmemorytothesamedegreeas

thestrategiesemployedinthemindfulnessconditions.Thestudythatbestcontrolsfor

sucheffectsisoneconductedbyTangetal.(2013).Theycomparedmindfulness

meditationwithrelaxationtrainingthatinvolvedguidedrelaxation,focusedondifferent

partsofthebody.Participantscompleted10daily30-minutesessionsofeither

mindfulnessmeditationorrelaxationtraining.Resultsshowedsignificantlyreduced

levelsofcravingat2weekscomparedtobaselineinthemindfulnessconditionbutnot

intherelaxationcondition.Thesefindingsprovidesupportforthenotionthat

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mindfulnesscanbringaboutreductionsincravingoverandabovewhatmightbe

achievedbydistractionorsimplevisualizationstrategies.Theyprovidesupportfor

Buddhistmodelsofcravingthatsuggestthatincreasedmetacognitiveawarenesshelps

motivatetheindividualtoavoidactingupontheircravings,whichinturnresultsina

reductionincravingfrequencyandstrength.Thefactthatthisstudyalsofounda

significantreductioninsmokinginthemindfulnessgrouprelativetotherelaxation

groupisconsistentwiththisview.However,contrarytothisinterpretation,participants

werenotselectedonthebasisofwantingtoquitsmoking,andthosewhointendedto

quitdidnotoutperformthosewithnointentiontoquit,suggestingthattheeffectson

behaviormaybemediatedbyunconsciousprocessing.Theauthorssuggestthatthey

mayhavebeenmediatedbystressreduction,thoughanalternativeexplanationisthat

theeffectsofincreasedmetacognitiveawarenessreferredtoinBuddhistmodels

prompttheindividualtoavoidrespondingtofeelingsofcravingevenwheretheydonot

holdgoalsthatareincompatiblewiththerelevantbehavior;itispossiblethatinsight

intothefutilityofpursuingcravingsissufficientforbehaviorchange.

Mostofthestudieswithinthisgroupemployedacombinationofstrategies,or

used‘mindfulnessmeditation’(Tangetal.,2013),or‘generalmindfulnesstraining’

(Davisetal.,2014)thatarelikelytohaveincorporatedseveraldifferenttypesof

mindfulnessstrategy.TheexceptionsareHooperetal.(2012)andMoffittetal.(2012)

whoexamineddecenteringinisolationandfoundatrendtowardhighercravingsinthe

decenteringconditionandnosignificanteffectrespectively.Similarly,Lacailleetal.

(2014)compareddifferentcombinationsofpresentmomentawareness,acceptanceand

decentering.Aftertwoweekstheyfoundnosignificantdifferenceincravingsfor

chocolateamongthosewhohadbeeninstructedtouseacceptance(eitherwithpresent

momentawareness,orwithpresentmomentawarenessanddecentering)but

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reductionsamongstthosewhohademployedpresentmomentawarenessinisolation

orpresentmomentawarenessplusdecentering.Incontrasttothestudiesconductedby

Hooperetal.(2012)andMoffittetal.(2012),participantswereinstructedtolistento5

minutesofaudioeveryday.Again,inlinewithEItheory,thesefindingsquestionthe

utilityofacceptancestrategiesforcravingreduction,atleastwhenemployedinthe

contextoflimitedmindfulnesstrainingandinrelationtoabehavioroneisnotintending

toquitcompletely.

Asnotedabove,theresultsofthestudybyTangetal.(2013)providesome

supportforBuddhistmodelsofcraving.Unlikeothermodelsofcraving,Buddhist

modelsalsopredictadecouplingofcravingandcraving-relatedbehaviors(seealso

Levinetal.,2015).Inotherwords,craving-relatedbehaviorsmaydeclineeveninthe

absenceofanyreductionincraving.Thisisassumedtobebecauseofincreased

metacognitiveawareness.ResearchbyBowenandMarlatt(2009)supportsthisview.

Theylookedattheeffectsofabriefpresentmomentawarenessandacceptance

interventiononsmokersinterestedincuttingdownorquitting.Althoughtheyfoundno

significanteffectonsmokingurges,eitherduringthemanipulation,24hourslateror7

dayslater,theydidfindareductioninthenumberofcigarettessmokedoverthe7-day

periodamongthoseinthemindfulnessgroup,butnotinthecontrolgroup.Similarly,

Elwafietal.(2013)reportedon33adultswhohadreceivedeightsessionsof

mindfulnesstrainingaspartofarandomizedcontrolledtrialforsmokingcessation.

Theyfoundthatwhilsttherewerestrongcorrelationsbetweenlevelsofcravingand

smokingatbaseline(r=0.582),theseweremuchlowerbytheendoftreatment(r=

0.126)suggestingthatthemindfulnesstreatmentwasdecouplingtherelationship

betweencravingandbehavior.Thisdecouplingeffectseemedtobedrivenbythe

amountofinformal,homepracticeparticipantsengagedin.However,theeffectwasnot

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sustainedwhenassessed2-weeksaftertheendoftreatmentorat3-or4-monthfollow-

ups,suggestingthatthedecouplingeffectmayonlybemaintainedforaslongasthe

individualcontinuestopracticethemindfulnessstrategies.

ThusthereisprovisionalsupportforsomeofthepredictionsmadebyBuddhist

modelsofcraving;firstthattheremaybereductionsincravingoverthemediumtolong

term,overandabovewhatmightbeachievedbyotherstrategiesthatinterrupt

elaborativeprocesses(Tangetal.,2013),andsecondthatoverthemediumtolongterm

theremaybeadecouplingbetweencravingsandcraving-relatedbehaviors(Bowen&

Marlatt,2009;Elwafietal.,2013).However,giventheverylimitednumberofstudies

theseconclusionsarebasedon,theyarenecessarilytentative.

Conclusions

Someofthebeneficialeffectsseenformindfulnessstrategiesinrelationto

cravingarelikelytostemfrom(a)interruptingcravingrelatedelaborationbyloading

workingmemory,and(b)extinctionprocessthatresultfromtheindividualinhibiting

thecraving-relatedbehavior.Whilstitisimportantnottodiminishthevalueofsuch

outcomes,itisunclearwhethermindfulness-basedstrategieshaveanyadvantagesover

othertechniquesthatalsopromotesucheffects.Forexample,guidedimagerymaybe

justaseffectiveatloadingworkingmemory,whilsteducationaboutresponse

suppressionmaybeequallyeffectiveatmotivatinganindividualtoresisttheircraving

urges.Furtherresearchcouldusefullycomparesuchapproaches.Inthemeantime,itis

importanttobeawarethatsucheffectsmaynotbeuniquetomindfulness-based

strategies.

However,akeyquestioniswhetherthesetypesofmindfulness-basedstrategies

mayhaveanadvantageoverotherstrategiesbecausetheyareeasiertosustainovera

longertimeframe.Forexample,learningtofocusonthepresentmomentwhencravings

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occurmaybeatechniquethatcanbemoreeasilyandflexiblyappliedinawiderangeof

differentsettingscomparedtoaspecificvisualizationstrategythatmayfeelmore

effortfuland,overtime,becomeratherrepetitive.Itisalsopossiblethatlevelof

meditationexperiencemoderatestheeffectsofsuchstrategies;mostofthestudiesthat

havetestedtheimmediateeffectsofpresentmomentawarenesstechniquesoncraving

wereconductedintheabsenceofmoreintensivemeditationtraining.Morelongitudinal

research,andresearchexamininguserviewsofdifferentstrategieswouldhelpaddress

suchquestions.

Thereisalsolimitedevidencetosupportthebeneficialeffectsofacceptance

strategiesoncravingand,aspredictedbyEItheory,apossibilitythatsuchstrategies

mayevenexacerbatecravings(Szaszetal.,2012)orunderminetheeffectsofother

strategies(Lacailleetal.,2014).Againhowever,sucheffectshaveonlybeenexamined

inthecontextofrelativelylimitedmindfulnesspractice;itispossiblethatacceptance

strategieshavedifferenteffectswhenemployedbythosewithmoreexperienceof

mindfulnessmeditation.

Thetheoryofgroundedcognitionpredictsthatdecenteringstrategieswould

reducelevelsofcravingoverandaboveanyeffectsthatoccurbecauseofworking

memoryload.However,onlyafewstudieshaveexamineddecenteringspecifically.

Wherebeneficialeffectshavebeenfound(Casellietal.,2016;Lacailleetal.,2014;

Papiesetal.,2015;Schumacheretal.,2017),replicationhasbeeninconsistent

(Schumacheretal.,2017)oritisdifficulttoruleoutthepossibilitythateffectsoccurred

duetoworkingmemoryload(Casellietal.,2016;Lacailleetal.,2014;Papiesetal.,

2015).Thus,atpresent,thereisanabsenceofgoodevidencetoshowthatdecentering

strategieshaveunique,immediatebeneficialeffectsoncraving.Additionalstudiesthat

manipulatedecenteringwhilstcontrollingforvisualizationareneeded.

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Morepromisingfindingsoccuramongthosestudiesthathaveaskedparticipants

toengageinregularpracticeofmindfulnesstechniques,andhaveassessedtheeffectsof

theseoveralongertimeframe.However,suchstudieswouldbenefitfromcontrolling

fortheeffectsofworkingmemoryloadinordertobetterestablishwhethersuch

interventionshavebenefitsoverandabovewhatmightbeachievedbysimple

distractionorvisualizationstrategies.

IntermsofthemodelsofcravingoutlinedinTable1,thereismostevidenceto

supportEItheory,togetherwiththeconditioningeffectsitencompasses.Inparticular,

researchsuggeststhatstrategiesthatloadworkingmemorybringaboutanimmediate

reductionincravings.Additionally,andconsistentwithEItheory,conditioningand

Buddhistmodelsofcraving,whereabehaviorisconsistentlysuppressed,present

momentawarenessandacceptancestrategiesmayleadtoamorerapidreductionin

cravingthanothertechniques.However,sincethisconclusionisbasedondatafromjust

onestudy(Nosen&Woody,2013),itshouldbeviewedaspreliminary.

ThereisalsosomeevidencetosupportBuddhistmodelsofcravinginrelationto

thedevelopmentofinsighteffectsandadecouplingofcravingandbehavior.However,

moreresearchwouldbeneededtofullytestthismodel.Longitudinaldatatracking

changeincravingsandbehaviorovertime,togetherwiththeirassociation,wouldbe

helpful.Likewise,therearecurrentlyinsufficientdatatofullytestthegrounded

cognitionaccountofcravingsorthecognitiveprocessingmodel.

RecommendationsforFutureResearch

Intermsoflaboratory-basedexperimentalwork,itwouldbehelpfulto

determinewhetherdecenteringstrategiescanhaveanimmediateeffectoncravingover

andabovewhatcouldbeachievedbysimplevisualizationordistractionstrategies.This

shouldberelativelyeasytoestablishwithstudiesthatcomparelevelsofcraving

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33

followingavisualizationanddecenteringtask,avisualizationonlytaskandano

strategycontrolgroup.Suchstudiesshouldhelpclarifytheimmediateeffectsof

decenteringandinformitsuseininterventiondevelopment.

Anotherimportantprioritymustberesearchthatexaminestheeffectsof

extendedperiodsofregularmindfulnesspractice.Whilstseveralstudiessuggestsuch

anapproachmaybepromisingfortacklingcravingsandcraving-relatedbehaviors,

existingdatamakeitdifficulttoidentifythemechanismsunderlyingsucheffectsandto

ruleoutmoreprosaicexplanations.Theuseofcarefullymatchedcomparisonconditions

thatcontrolforfactorssuchashaloeffectsandworkingmemoryloadwouldhelptest

Buddhistaccountsofcravingandestablishwhethermindfulnesspracticecaninfluence

cravingandcraving-relatedbehaviorsoverandabovealternativeapproaches.Such

studieswouldbenefitfromincludinglongitudinalmeasuresofcravingandbehaviorin

ordertotrackchangesovertime.Again,thiswouldhelptestBuddhistmodelsaswellas

informthedevelopmentofinterventions.Likewise,manipulating,oratleastmeasuring,

frequencyandlengthofpracticewouldalsohelpidentifyanyminimallevelofpractice

thatisrequiredtoseebenefits.

Relatedly,moremeasuresareneededtoidentifythemechanismsunderlyingany

beneficialeffectsofmindfulness.Itseemslikelythatincreasedself-efficacyandreduced

stressand/ornegativeaffectmayplaysomerole,thoughmeasuresofthesetendnotto

havebeenincludedinstudiesofcraving.Itwouldberelativelystraightforwardto

incorporatesuchmeasuresinfuture.

Likewisethereisevidencetosuggestthatmindfulnesscanimproveattention

regulation(Chiesaetal.,2011;Mrazeketal.,2013).Improvementsinattention

regulationmaybringaboutreductionsincravingbyreducingattentionalbiasandalso

byhelpingindividualsmaintaintheirattentiononwhatevertaskisathand,ratherthan

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engageincognitiveelaborationofcraving-relatedthoughts.Althoughthereissome

evidencetosuggestthatmindfulness-basedinterventioncanreduceattentionalbias

(Garland&Howard,2013),suchpossibilitieshaveyettobefullyexploredinmore

controlledstudiesofmindfulnessandcraving.

Similarly,researchbyTangetal.(2013)raisesthequestionofwhethereffects

aremediatedbyconsciousversusunconsciousprocesses.Thisisworthexploringasit

hasimplicationsforthetypesofpopulationswhomaymostbenefitfrommindfulness-

basedinterventions;ifeffectsaremediatedbyunconsciousprocessesthenan

individual’smotivationtochangetheirbehaviormaybelessimportant.Wemayalso

seeeffectsgeneralizingacrossawiderangeofdifferentdomains.However,ifeffectsare

mediatedbyconsciousprocesses,interventionsmaybebettertargetedatthosewhoare

alreadymotivatedtochangetheirbehavior.Wemayalsoexpecteffectstobemore

domainspecific.

Anotherimportantareaforfutureresearchistoconsiderwhetheranybeneficial

effectsofmindfulnessdifferbetweenthosewhoexperiencecravingswithinthecontext

ofclinicaldisordersversusthosewhoexperiencetheminotherareas,suchaswhen

tryingtoloseweightoreatmorehealthily.Giventhatindividualswithsubstanceuse

disorderstendtoexhibitdysregulatedneurocognitiveprocesses(Koob&Volkow,

2010)itseemsplausiblethateffectsmaydifferbetweenclinicalandnon-clinical

populations.Thestudiesincludedinthecurrentreviewcomprisemainlyofthose

withoutaclinicaldiagnosis,withjustonestudy(Casellietal.,2016)focusingon

individualsatanaddictioncenter.Itispossiblethatbeneficialeffectsofmindfulnesson

cravingonlyemergeformoresevereinstancesofcraving.Assuch,moreexperimental

workconductedwithclinicalpopulations,wouldbeinformative.Dismantlingstudiesof

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35

multi-componentinterventionsforclinicalpopulationswouldalsobehelpful,inorder

toestablishtheuniquecontributionofthemindfulness-basedelements.

Finally,researchersshouldtakecaretodescribeindetailthestrategies

employedinanymindfulnessstudy,togetherwithanycomparisonconditions.As

illustratedinthecurrentreview,awiderangeofdifferentpracticesarelabeledas

mindfulnessbut,accordingtoanumberoftheories,thesewillnotnecessarilyhave

equivalenteffects.Havingfulldetailsofsuchprocedureswillallowforeasierandmore

accuratecomparisonsacrossstudies.

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36

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AppendixACharacteristicsofStudiesExaminingtheIndependentEffectsofMindfulnessonCravingCravingtype

Study Samplesize1

Sampledetails

Gender(%

female)

Primarymindfulnessstrategy(ies)/intervention

Controlstrategy(ies)/intervention

Dependentvariable

Results2

Food Hamiltonetal.(2013)

94 Universitystudents,abstainedfrombreakfast.

77% Presentmomentawarenessofbodilysensationsandthoughts.

1.Guidedimagery.2.Mindwandering.

Foodcravingsattentime-pointsduringthemanipulation.

Nosignificantdifferencebetweenthemindfulnessandimageryconditions.Cravingshowedasignificantincreaseinthemindwanderingconditionbutnotinthemindfulnessorimageryconditions.

Cigarettes Bowen&Marlatt(2009)

123 Universitystudents,smokersinterestedincuttingdownorquitting,abstinentforatleast12hours.

27% Presentmomentawarenessandacceptanceofthoughts,sensationsandurges.

Askedtocopewithurgesinthemannertheyusuallywould.

Smokingurgesassessedat4timepointsduringthemanipulation,duringacueexposuresession.

Nosignificantdifferences.

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Smokingurges24hourslater.

Nosignificantdifferences.

Smokingurges7dayslater.

Nosignificantdifferences.

Alcohol Casellietal.(2016)

8(repeatedmeasuresdesign)

Patientsatanaddictioncenterwithadiagnosisofalcoholusedisorder,abstinentfromalcohol,aged35-50years.

50% Decenteringfromapre-recordedaudiooftheirownalcoholrelatedthoughts.

Habituationtoapre-recordedaudiooftheirownalcoholrelatedthoughts.

Intensityofurgetodrinkassessedat1,3and5minutesduringthemanipulation.

Significantlygreaterdecreasesinthemindfulnesscondition.

Food Archetal.(2016)

81 Universitystudents.

59% Presentmomentawarenessofthesensorypropertiesoffood.

Wordpuzzles. Desiretoeatanotherchocolatechip,assessedonfiveoccasions,eachimmediatelyafterapplyingthestrategy.

Atrendtowardshigherdesireinthemindfulnesscondition;p=.056.

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136 Universitystudents.

77% Presentmomentawarenessofthesensorypropertiesoffood.

Wordpuzzles. Desiretoeatanotherraisin,assessedonfiveoccasions,eachimmediatelyafterapplyingthestrategy.

Higherdesireinthemindfulnesscondition.

102 Universitystudents,abstainedfromeatingforatleast2hours.

42% Presentmomentawarenessofthesensorypropertiesoffood.

1.Wordpuzzles.2.Nostrategy.

Desiretoeatanotherraisin,assessedonfiveoccasions,eachimmediatelyafterapplyingthestrategy.

Nosignificantdifferencebetweengroupsinoveralllevelofdesire.Thoseinthemindfulnessconditionshowedasteeperinitialincreaseandslowerdeclineindesireoverthefivetime-points.

Alcohol Vincietal.(2014)

207 Collegestudents,reportingat-riskdrinking,endorsement

76% Presentmomentawarenessofbodilysensations,

1.Relaxation.2.Nostrategy.

Urgetodrinkimmediatelyafterthemanipulation.

Nosignificantdifferences.

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ofaffective-regulationmotivesfordrinking.

acceptance. Urgetodrinkimmediatelyafterpracticingthestrategyduringaneutralornegativemoodinduction.

Significantincreasesinthemindfulnessandrelaxationconditions,afteranegativemoodinduction.

Cigarettes Adamsetal(2013)

64 Universitystudents,smokers,temporarilyabstinent.

100% Presentmomentawarenessofbreath.Presentmomentawarenessandacceptanceofthoughtsandfeelings.

Nostrategy. Desiretosmokeimmediatelyafterthemanipulationthatwaspresentedsimultaneouslywitheitherabodyimagechallengeornobodyimagechallenge.

Nosignificantdifferences.

Cigarettes Westbrooketal.(2013)

54 Communitysample,smokeatleast10cigarettesaday,strongdesiretoquitwithinthefollowingmonth,temporarily

31% Presentmomentawarenessandacceptanceofthoughts,feelings,memoriesandbodilysensations.

Nostrategy. Cigarettecravingassessedon12occasions,eachimmediatelyafterapplyingthestrategywhilstviewingsmokingrelatedimages.

Significantlylowercravingsinthemindfulnesscondition.

MINDFULNESS

43

abstinent.

Food Papiesetal.(2015)

75 Universitystudents.

Notreported

Decenteringfromreactionstopicturesoffood.

Viewingpicturesoffoodinarelaxedmanner.

Foodcravingsimmediatelyfollowingthemanipulation.

Atrendtowardslowercravingsinthemindfulnesscondition;p=.058.

Cigarettes May,Andrade,Willoughbyetal.(2012)

27 Universitystaff,students,friendsandfamily,smokeatleast10cigarettesadayoverthelast6months,abstinentforatleast2hours.

59% Presentmomentawarenessofbodilysensations.

Mindwandering.

Cigarettecravingsimmediatelyafterthemanipulation.

Significantlylowercravingsinthemindfulnesscondition.

Cigarettecravingsafterasubsequent10-minutemindwanderingsession.

Nosignificantdifference.

Food Schumacheretal.(2017)

94 Universitystudents,likechocolate

100% Decenteringfromthoughtsaboutchocolate

1.Guidedimagery2.Mindwandering

Intrusivenessofchocolatecravingsimmediatelyfollowingthemanipulation.

Significantreductioninthedecenteringcondition;nochangeintheimageryormindwanderingconditions.

MINDFULNESS

44

Vividnessofchocolatecravingsimmediatelyfollowingthemanipulation.

Significantreductioninthedecenteringcondition;nochangeintheimageryormindwanderingconditions.

Intensityofchocolatecravingsimmediatelyfollowingand10minutesafterthemanipulation.

Significantreductioninthedecenteringcondition,maintainedat10minutes;nochangeintheimageryormindwanderingconditions.

97 Universitystudents,cravechocolateatleastonceaday,wanttoreducetheirconsumptionofchocolate.

100% Decenteringfromthoughtsaboutchocolate

1.Guidedimagery2.Mindwandering

Intrusivenessofchocolatecravingsimmediatelyfollowingthemanipulation.

Significantreductionsacrossallthreeconditions.

Vividnessofchocolatecravingsimmediatelyfollowingthemanipulation.

Significantreductionsacrossallthreeconditions.

MINDFULNESS

45

Intensityofchocolatecravingsimmediatelyfollowingand10minutesafterthemanipulation.

Significantreductioninthedecenteringandimageryconditions,maintainedat10minutes;nochangeinthemindwanderingcondition.

Food Fisheretal.(2016)

40 Universitystaffandstudents.

100% Presentmomentawarenessofthoughts,emotionsandbodilysensations.

Audiodescriptionofarainforest.

Foodcraving10minutesafterthemanipulation.

Nosignificantdifference.

Foodcravingimmediatelyafter10minutesofself-practice/sittinginthepresenceoffoods.

Nosignificantdifference.

Desiretoeat10minutesafterthemanipulation.

Nosignificantdifference.

Desiretoeatimmediately

Nosignificantdifference.

MINDFULNESS

46

after10minutesofself–practice/sittinginthepresenceoffoods.

Food

Mayetal.(2010)

48

Universitystudents,tryingtocutdownonsnackfoods,abstainedfromeatingfor2hours.

81% Presentmomentawarenessofthebreath,decenteringfromthoughtsaboutsnackfoods.

1.Thoughtsuppression.2.Imagerydiversion.3.Mindwandering.

Cravingforsnackfoodimmediatelyfollowingthemanipulation.

Nosignificantdifferencesbetweenthemindfulness,imagerydiversionandmindwanderingconditions.Significantlylowercravingsinthethoughtsuppressioncondition

Cravingforsnackfood10minutesafterthemanipulation.

Nosignificantdifferences.

49 Universitystudents.

63% Presentmomentawarenessofbodilysensations.

1.Guidedimagery.2.Mindwandering.

Cravingforsnackfoodimmediatelyfollowingthemanipulation.

Nosignificantdifferences.

MINDFULNESS

47

Cravingforsnackfood10minutesafterthemanipulation.

Nosignificantdifferences.

Cigarettes Cropleyetal.(2007)

30 Samplerecruitedviaadvertsatauniversity,smokedatleast10cigarettesadayforatleast3consecutiveyears.

40% Presentmomentawarenessofbodilysensations.

Audiorecordingofanaturalhistorytext.

Strengthofdesiretosmokeimmediatelyfollowingthemanipulation.

Significantlylowerinthemindfulnessgroup.

Strengthofdesiretosmoke5minutesafterthemanipulation.

Significantlylowerinthemindfulnessgroup.

Strengthofdesiretosmoke10minutesafterthemanipulation.

Nosignificantdifference.

Strengthofdesiretosmoke15minutesafterthemanipulation.

Nosignificantdifference.

Food Albertsetal(2013)

61 Universitystudents.

80% Presentmomentawarenessof

1.Suppressionofcravingsandcravingrelated

Foodcravingsimmediatelyfollowingthe

Nosignificantdifferencebetweenthemindfulness

MINDFULNESS

48

foodcravings,acceptanceoffoodcravingsandcravingrelatedthoughts.

thoughts.2.Nostrategyandoptiontoeatfood.

manipulation. andsuppressiongroups.Significantlyhighercravingsinthemindfulnessandsuppressionconditionscomparedtothenostrategycondition.

Foodcraving20minutesafterthemanipulation.

Nosignificantdifferencebetweenthemindfulnessandsuppressiongroups.Significantlyhighercravingsinthemindfulnessandsuppressionconditionscomparedtothenostrategycondition.

Cigarettes Ussheretal.(2009)

48 Communitysample,ordinarilysmokedatleast10cigarettesadayforatleast3years,

35% Presentmomentawarenessofbodilysensations.

1.Isometricexercises.2.Audiorecordingofanaturalhistorytext.

Strengthofdesiretosmokeimmediatelyfollowingtheinterventioninthelaboratory.

Significantlylowerinthemindfulnessconditioncomparedtothetextcondition.Nosignificantdifferencebetweenthemindfulness

MINDFULNESS

49

temporarilyabstinent.

andisometricconditions.

Strengthofdesiretosmoke5minutesaftertheinterventioninthelaboratory.

Significantlylowerinthemindfulnessconditioncomparedtothetextcondition.Nosignificantdifferencebetweenthemindfulnessandisometricconditions.

Strengthofdesiretosmoke10minutesaftertheinterventioninthelaboratory.

Significantlylowerinthemindfulnessconditioncomparedtothetextcondition.Nosignificantdifferencebetweenthemindfulnessandisometricconditions.

Strengthofdesiretosmoke30minutesaftertheintervention

Significantlylowerinthemindfulnessconditioncomparedtothe

MINDFULNESS

50

inthelaboratory.

textcondition.Nosignificantdifferencebetweenthemindfulnessandisometricconditions.

Strengthofdesiretosmokeimmediatelyaftertheinterventionoutsidethelaboratory.

Significantlylowerinthemindfulnessconditioncomparedtothetextcondition.Nosignificantdifferencebetweenthemindfulnessandisometricconditions.

Strengthofdesiretosmoke5minutesaftertheinterventionoutsidethelaboratory.

Significantlylowerinthemindfulnessconditioncomparedtothetextcondition.Nosignificantdifferencebetweenthemindfulnessandisometricconditions.

MINDFULNESS

51

Strengthofdesiretosmoke30minutesaftertheinterventionoutsidethelaboratory.

Nosignificantdifferences.

Cigarettes Szaszetal.(2012)

94 Universitystudents,smokemorethan10cigarettesaday,havesmokedforatleast1year,wouldliketoquit.

88% Acceptanceofthoughtsandfeelings.

1.Reappraisal.2.Suppression.

Cigarettecravingsassessedatfourtimepoints:baseline,followingthemanipulation,followinga3-minutecravinginduction,followingadotprobeandserialadditiontask.

Nosignificantdifferencesbetweenthemindfulnessandsuppressiongroups.Cravingssignificantlylowerinthereappraisalgroupcomparedtothesuppressionandmindfulnessgroups.

Alcohol Murphy&MacKilop(2014)

84 Communitysample,heavydrinkers,aged21-29years.

50% Presentmomentawarenessofexperienceincludingcravings,acceptance,decentering.

1.Distraction.2.Nostrategy

Alcoholcravingassessedatseventimepointsimmediatelyfollowingthemanipulation.

Nosignificantdifferencebetweenthemindfulnessandnostrategyconditions.Significantlylowercravingsinthedistractioncondition.

MINDFULNESS

52

Distressfromalcoholcravingassessedatseventimepointsimmediatelyfollowingthemanipulation.

Nosignificantdifferencebetweenthemindfulnessandnostrategyconditions.Significantlylowerdistressinthedistractioncondition.

Alcoholcraving1weeklater.

Nosignificantdifferences.

Cigarettes

Nosen&Woody(2013)

122 Communitysample,smokedatleast10cigarettesadayfortheprevious2years,expressedacommitmenttoquit.

35% Presentmomentawarenessandacceptanceofcravings.

1.Standardpsycho-education;informationaboutsmokingcessationmethods.2.Notreatment.

Eightassessmentsofsmokingurgesduringa1-dayperiodofad-libsmoking,thedayafterthemanipulation.

Nosignificantdifferences.

Eightassessmentsofsmokingurgesduringa1-dayperiodcoincidingwithaquitattempt,thedayafterthe

Significantlylowerinthemindfulnessgroupcomparedtothepsycho-educationandnotreatmentgroupsintheevening.Significantlylower

MINDFULNESS

53

manipulation. inthemindfulnessgroupcomparedtothenotreatmentgroupinthemorning.Nosignificantdifferencebetweenthemindfulnessgroupandpsycho-educationgroupinthemorning.Nosignificantdifferencesbetweengroupsduringmidday/afternoon.

Smokingurges4dayslater,aftermanipulation.

Nodifferencesbetweengroups.

Food Formanetal(2013)

48 Communityparticipants,overweightorobese.

100% Acceptanceofcravings,decenteringfromcravings.

Distractionandcognitiverestructuring.

Sweetcravingassessedatthreetimepointsperdayover3days.

Nosignificantdifference.

Food Hooperetal.(2012)

47 Universitystudents,notdieting.

59% Decenteringfromfeelingsofchocolatecravingandthoughtsabout

1.Thoughtsuppression.2.Nostrategy.

Frequencyofchocolatecravingsexperiencedover6days,

Atrendtowardsasignificantgroupdifference,withthoseinthemindfulness

MINDFULNESS

54

chocolatecraving.

reportedattheendofeachday.

conditionexperiencingmostcravings,andthoseinthenostrategyconditionexperiencingleastcravings;p=.091.

Food Moffittetal.(2012)

110 Communitysample,regularlycraveandeatchocolate,desiretobettermanageeatingbehaviors.

85% Decenteringfromfoodrelatedthoughts.

1.Cognitiverestructuringoffoodrelatedthoughts.2.Nostrategy.

Strengthofchocolatecravingsexperienced‘throughoutthedaytoday’,assessed7daysaftertheintervention.

Nosignificantdifferences.

Traitfoodcravings7daysaftertheintervention.

Nosignificantdifferences.

Food Lacailleetal.(2014)

126

Samplerecruitedfrominandaroundauniversity,

89%

Presentmomentawarenessofcravings.

Recitalofthealphabetthenmultiplesof2suntil100.

Traitchocolatecravings2weeksaftertheintervention.

Significantlylowercravingsinthemindfulnesscondition.

MINDFULNESS

55

chocolatecravers,interestedinreducingchocolatecravings.

Chocolatecravingsfollowingacravinginductionadministered2weeksaftertheintervention.

Significantlylowercravingsinthemindfulnesscondition.

Presentmomentawarenessandacceptanceofcravings.

Traitchocolatecravings2weeksaftertheintervention.

Nosignificantdifference.

Chocolatecravingsfollowingacravinginductionadministered2weeksaftertheintervention.

Nosignificantdifference.

Presentmomentawarenessanddecenteringfromcravings.

Traitchocolatecravings2weeksaftertheintervention.

Significantlylowercravingsinthemindfulnesscondition.

Chocolatecravingsfollowinga

Significantlylowercravingsinthemindfulness

MINDFULNESS

56

cravinginductionadministered2weeksaftertheintervention.

condition.

Presentmomentawareness,acceptanceanddecenteringfromcravings.

Traitchocolatecravings2weeksaftertheintervention.

Nosignificantdifference.

Chocolatecravingsfollowingacravinginductionadministered2weeksaftertheintervention.

Nosignificantdifference.

Cigarettes

Ruscioetal.(2016)

44 Communitysample,18-65yearolds,smokedatleast10cigarettesadayforatleast2years.

50% Presentmomentawarenessofbodilysensations,thoughtsandemotions.Present

Shammeditation.

Urgetosmokeassessedatfourrandomtimepointsthroughoutthedayoveraperiodof2weeks.

Nosignificantdifference.

MINDFULNESS

57

momentawarenessandacceptanceofurgesandcravings.

Urgetosmokeassessedimmediatelyaftercompletingdailymindfulorshammeditationoveraperiodof2weeks.

Significantlylowerinthemindfulnessgroup.

Cigarettes

Tangetal.(2013)

27 Universitystudents,smokerswithnointentiontoquit.

30% Mindfulnessmeditation

Relaxation

Severityofcravingstosmokebeforeandafter2weeksoftraining.

Significantlyreducedcravingsinthemindfulnessconditionbutnotthecontrolcondition.

MINDFULNESS

58

Cigarettes

Davisetal.(2014)

95

Communitysample,livinginareasoflowsocio-economicstatus,smokingatleast5cigarettesaday,highmotivationtoquit.

48%

Generalmindfulnesstraining.

Standardsmokingcessationintervention.

Strengthofsmokingurgesovertheprevious24hours,assessedviatelephoneonthreeoccasionsduringtheweekbeforeandthreeoccasionsduringtheweekafterthequitdate.Thequitdatewasscheduledduringweek5oftheintervention.

Significantlygreaterreductioninpostquitversusprequiturgesinthemindfulnesscondition.

Food

Albertsetal(2010)

19

Communitysample,overweightorobese.

89%

Presentmomentawarenessofbodilysensations,eatingbehaviorsandcravingrelatedthoughts.

Informationandphysicalactivity.

Traitfoodcravings7weeksfrombaseline.

Significantlygreaterreductionincravingsinthemindfulnesscondition.

MINDFULNESS

59

1Restrictedtoparticipantsincludedintheanalysesofinterest.2Differencesarestatisticallysignificant,unlessotherwisestated.

Acceptanceofcravingrelatedbodilysensationsandthoughts.