Addiction (2000) 95 (Supplement 2), S237

S246
SYNTHESIS AND FUTURE DIRECTIONS IN CRAVING RESEARCH
Transdisciplinary concepts and measures of
craving: commentary and future directions
DAVID B. ABRAMS
Brown University Center for Behavioral and Preventive Medicine,
Brown University School of Medicine and The Miriam Hospital, Providence,
Rhode Island, USA
Abstract
A new theoretical model of craving is needed that uses a common language and standardized measures. The
new conceptual model must fully integrate discoveries from cellular biology, neuroscience, animal and human
laboratory, cognitive

behavioral social learning and socio-cultural disciplines. A transdisciplinary synthesis

can then guide methods and measurement development. Mapping the structural pathways and interactions
among mediators and moderators of craving will improve the diagnostic and prognostic tools in order to inform
new treatments and prevention strategies.
Introduction
The question of what exactly is craving and how
should it be measured is a complex one that
remains unsolved. This question can be enriched
by the diversity of disciplines, levels of analysis
(from the cellular to the psychophysiological to
the cognitive to the behavioral and socio-
cultural) and theoretical models that underlie the
papers presented at the Workshop on Treatment
and Alcohol Craving: Extending the Paradigm,
sponsored by the US National Institute on Al-
cohol Abuse and Alcoholism (for details see
Lowman et al., 2000). How craving is conceptu-
alized has implications for measurement, for
understanding its role in mediating addictive be-
havior and for treatment and prediction of treat-
ment outcomes.
Ultimately, craving must emerge as a con-
struct that adds unique explanatory variance
above and beyond other addiction-related con-
structs. Craving must be useful in contributing
to the measurement of individual differences that
predict why some individuals, under certain cir-
cumstances, will have difculty controlling their
addictive behaviors or will be prone to relapse,
while others will not. A measure of craving could
reect several biopsychosocial concepts includ-
ing a meaningful differentiation of individuals
along a continuum, variation within individuals
over time, or perhaps distinct clusters or sub-
types of individuals. If craving can be measured
reliably and if it has unique explanatory power,
then the concept would sharpen the distinction
between diagnostic categories, improve prognos-
tic indicators of the severity of addiction and
enhance our theories as well as the development
of more effective tailored treatment and preven-
tion.
Correspondence to: David B. Abrams PhD, Director, Brown University Center for Behavioral and Preventive
Medicine, The Miriam Hospital, 164 Summit AvenueRISE Building, Providence, RI 02906, USA.
Submitted1st September 1999; initial reviewcompleted 16thNovember 1999; nal version accepted 17thJanuary
2000.
ISSN 09652140 print/ISSN 13600443 online/00/08S23710 Society for the Study of Addiction to Alcohol and Other Drugs
Carfax Publishing, Taylor & Francis Ltd
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Biological
Behavioral
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Environmental
Craving
S238 David B. Abrams
In order to advance our understanding of crav-
ing, it is necessary to clearly dene the construct
from a biopsychosocial perspective and ensure
that a common language and standard way of
measuring craving is developed. Before examin-
ing the current denitions of craving several
methodological and conceptual issues must be
considered. Ideally, for a measure to be clinically
useful it must be reliable, valid and have sufcient
sensitivity and specicity to discriminate known
groups that warrant different tailored interven-
tions resulting in signicantly enhanced treat-
ment outcomes. In short, the construct and
measurement of craving must be theoretically
based, empirically anchored, psychometrically
sound, reliable and practical in terms of con-
struct, predictive and discriminant validity
(Tiffany et al., 2000). The conceptualization and
measurement of craving is likely to be multi-di-
mensional including biological, psychological and
socio-cultural or contextual components (see Fig.
1). As illustrated in the structural model of a
simplied three-dimensional interaction between
the broad domains of biological, cognitive

behav-
ioral and socio-cultural and physical environ-
ments, many combinations of relationships are
possible. Each domain is considered to be a
continuum from low vulnerability (-) to high
vulnerability ( 1). For example, in the front, top,
left cell of the cube in Fig. 1, the highest level of
craving would be expected to result from a three-
way interaction of highest vulnerability in all three
domains (biologically sensitive; poor cognitive

behavioral coping skills; and a set and setting that

produces maximal social-cultural temptations
and cues to drug use and/or ease of access to
drugs). The three major parameters of craving
(biopsychosocial) could be conceptualized as an
additive model. It is unclear whether the domains
are relatively independent, additive or interactive.
The relative contributions of the three domains
could also differ across individuals or time, result-
ing in different weightings of variables in each
domain.
Figure 1. Biopsychosocial dimensions of craving. Each of the eight cells within the three-dimensional (23232) cube
represents a three-way interaction among biological, cognitive

behavioral and environmental (social and physical) dimensions

of vulnerability. The resulting interaction would predict the level of craving and hence ultimate vulnerability to relapse. Six
of the possible eight combinations of three-way interactions are illustrated on the front face and the side face of the cube. For
example, the top, left, front cell of the cube represents maximum vulnerability due to high biological sensitivity; weak
cognitive

behavioral coping skills to resist temptation; and the presence of powerful environmental cues such as social pressure,
drug-specic stimuli and ease of access to the drug of choice. By contrast, the bottom, right, side cell of the cube represents maximal
protective factors of low biological sensitivity; strong behavioral coping skills and absence of environmental cues.
Transdisciplinary concepts and measures of craving S239
Towards a transdisciplinary conceptualiza-
tion of craving
Several researchers in the last decade have ac-
knowledged a variety of biological, psychological
and culturally driven perspectives on craving and
noted that advancement in craving research is
hampered by different denitions and inconsist-
ent measures that probably reect different as-
sumptions and conceptualizations of craving
(Kozlowski & Wilkinson, 1987). It is rarely the
case that models at the biological level (cellular,
genetic, molecular, cognitive neuroscience, ani-
mal and human laboratory research) are inte-
grated with applied clinical or public health
perspectives (cognitive behavioral models of ad-
diction, treatment outcomes research).
At its core, craving is typically dened as a
subjective experience within ones awareness that
reects retrieval from the memory systems of a
strong learned desire to satisfy an actual (e.g.
biological) or perceived need. Kozlowski &
Wilkinson (1987) recommend the word urge
for non-pathological or less intense craving. Al-
though this distinction highlights the question of
a craving threshold it does not solve the prob-
lem of whether urges and craving are qualita-
tively different or in a continuum (see later).
From a broader transdisciplinary perspective,
craving would be associated with subjective
norms derived from its socio-cultural meaning
(e.g. Quintero & Nichter, 1996) that ultimately
resides in human memory in some form of cog-
nitive schemata (Shadel, Niaura & Abrams, in
press). The cognitive schema are poorly under-
stood but probably evolve over time via neuroad-
aptive learning mechanisms including cellular
changes, classical and operant conditioning, ob-
servational learning and other symbolic pro-
cesses that are inuenced by role models,
mass-media portrayals and cultural norms. Such
broader mechanisms are captured in Banduras
cognitive social learning theoryCSLT (Abrams
& Niaura, 1987; Bandura, 1986, 1997; Niaura,
2000).
Recent advances in cognitive neuroscience
have begun to link animal and human models
from the cellular, neurochemical and infor-
mation processing disciplines. At the level of
memory, for example, White (1996) suggests
that drugs as reinforcers come to change behav-
ior through actions on multiple memory systems
through: (a) activation of observable approach or
escape responses; (b) unobservable internal cues
perceived as rewarding or aversive; and (c)
modulation of information stored in memory.
The amygdala circuitry is responsible for con-
ditioned incentive learning; the caudate

putamen for habiti.e. repetition of behaviors

performed in the presence of drug-related stim-
uliand the hippocampus for declarative mem-
ory concerning information about relationships
among external cues, internal affective states and
situations. Declarative memory promotes the fo-
cusing of attention on cognitive processing of
drug-related associations. White (1996) suggests
that incentive and habit learning are largely un-
conscious processes and require post-hoc explana-
tions that enter into the declarative memory
system. Whites model is based primarily on
animal research and is not universally accepted.
However, if true, it could pose some challenges
for a concept such as craving. Under Whites
(1996) model, craving presumably would reside
in the hippocampal circuitry of declarative mem-
ory within human consciousness. Craving would
have little predictive power because it consists of
a post-hoc explanation of the individuals behav-
ior as a result of largely unconscious processes.
This example simply begins to illustrate the
difculty with dening and measuring craving,
even from within a single disciplinary perspec-
tive.
In a broader transdisciplinary conceptualiza-
tion of craving, the biological substrate (the
hardware) provides a fundamental source of in-
dividual differences (e.g. genetic differences in
sensitivity to drug exposure or challenge, toler-
anceacute, subacute and chronic). Memory of
past exposure becomes linked to experiences
with addictive behavior and results in expectan-
cies that drive current and future behavior within
specic contexts of set and setting. Craving may
be considered as proximal goal setting directed
by one or more memory units that comprise the
satisfying perceived biological needs and
craving schemata. Triggered by discriminative
stimuli (cues), the craving schemata produces an
expectation that goal attainment (through addic-
tive behavior) is the best or only means of
achieving desired outcomes. Consistent with
CSLT, Marlatt & Gordon (1985) suggest that
the term craving represents a desire for the ef-
fects of the drug (outcome expectations), while
urge is the behavioral intention to use (proximal
goal setting).
Since individuals are viewed in the CSLT
S240 David B. Abrams
framework as both agents and recipients of
change (reciprocal determinism), craving could
be conceptualized as a powerful cognitive
schema that strongly predicts future behavior
and reects the integration of all relevant
memory systems including those derived from
the culture (e.g. by observing others behavior).
In Banduras (1997) CSLT framework, outcome
and efcacy expectations play the central role in
predicting behavior. Goldman, Brown & Chris-
tiansen (1987) point out that much learning
about how to regulate ones behavior (when
seeking and taking drugs) can be acquired in
childhood before any drugs are ingested at all. In
fact, an addictive behavioral pattern could de-
velop without the drug having any psychoactive
effect on the brainat least in principle through
vicarious (observational) learning. It is easier to
see the power of this line of reasoning if one
considers behavioral addictions such as gam-
bling. In the cognitive

behavioral model of
CSLT, craving is simply a learned expectation
that could vary dramatically across different sub-
stances, people, situations, occasions and cul-
tural norms. Moreover, the variability can be
observed across individuals with relatively similar
underlying biological substrates or genetic vul-
nerabilities. Thus, one could not reduce craving
to its fundamental biological mechanisms with-
out evoking additional cognitive explanatory
constructs. Biological variability would interact
with cognitive, behavioral and socio-cultural
variables (Goldman, Del Boca & Darkes, 1999;
Sayette, 1999).
In order to sharpen the boundaries con-
cerning what constitutes craving, it may be use-
ful to not only compare and contrast craving
concepts across levels of analysis (neuro-
biological, cognitive social learning) and across
different drugs of abuse (e.g. alcohol, nicotine,
cocaine, cannabis, heroin, amphetamines), but
also across other behaviors that may contain
both similarities and important differences in
their mechanisms of action and behavioral
expression (e.g. compulsive gambling, disorders
of impulse control, eating disorders such as
bulimia nervosa and obsessive compulsive dis-
orders in general). The overlap between
craving and compulsive use is illustrated in the
development and predictive value of the obsess-
ive compulsive drinking scale (Anton, Moak &
Latham, 1996; Anton, 2000). The differences in
mechanisms may be more important than the
similarities. It is often easier to see the similari-
ties. While several researchers have suggested
that eating disorders are a form of addictive
behavior, Wilson (1995), for example, argues
that the similarities are largely supercial, and
the differences support the theory that eating
disorders are not within the class of addictive
behaviors.
Moreover, expanded conceptual models that
bridge biological, cognitive neuroscience and
CSLT theories may help to further clarify the
precise nature, scope and boundaries of craving.
Koob & LeMoal (1997) and Koob (2000)
provide the kind of broad conceptual inte-
gration that serves to illustrate the power of
interdisciplinary thinking. Their model of
hedonic homeostatic dysregulation (at the neu-
robiological level) actually has striking parallels
with CSLT theory of reciprocal determinism
and the downward spiral of the drug addict
(at the cognitive

behavioral

social level) into a

drug subculture, as described in Abrams &
Niaura (1987)a vicious cycle culminating
in social isolation and a narrowing of the behav-
ioral repertoire to a drug-lled environment
(p. 139).
For craving to become a meaningful construct
within a broadened theory of addiction, it must
add unique variance to predicting outcome.
Craving implies a sufciently intense desire to
use the drug of choice, reecting a maladaptive
process. At some critical point along the pathway
to actual drug use, the brains reward mecha-
nisms are hijacked by the specic substance and/
or the learned associations of positive outcome
expectations, resulting in a narrowing of the
behavioral repertoire, a strong predisposition for
actual use or compulsive use that is ego dys-
tonic. Here craving refers to and probably pre-
dicts a failure to be able to abstain, imminent
relapse or loss of control following a period of
abstinence (Kozlowski & Wilkinson, 1987). The
key question is whether the individuals aware-
ness of a growing intensity of urge or desire to use
the drug actually becomes the craving that
causally predicts drug use by setting in motion
the proximal goal-directed behavior that cannot
be stopped. Is craving causally predictive of out-
come or is it an epiphenomenona post-hoc by-
product of other mechanisms/processes? What
kind of conceptual models of addiction and what
research methods can help us answer this
question?
Transdisciplinary concepts and measures of craving S241
Methods, metrics mediators and modula-
tors of craving in treatment research
It remains unclear whether craving is a continu-
ous linear, curvilinear or a discontinuous
phenomenon. If the phenomenon is continuous,
then a sharp distinction between an urge and
craving as recommended by Kozlowski &
Wilkinson (1987) may not be the most helpful
distinction to make. Does an urge versus a crav-
ing ultimately reect a reliable and meaningful
clinical distinction between problematic and
non-problematic behavior? If craving is a discon-
tinuous phenomenon, then what is the threshold
or cut-point for a step function model of craving?
A step function denes an abrupt qualitative
change from one point in time to the nexta
discontinuity. Most important, can individual
addicts reliably differentiate between an urge
(presumably that is under self control) and a
craving (that results in loss of control)? In short,
is one persons urge another persons craving?
While researchers today debate whether crav-
ing is a continuous or a step function, it should
be pointed out that there are other contextual
variables that may strengthen or attenuate the
relationship between craving, compulsive drug
use and poor treatment outcome. These other
variables might modulate craving and thereby
help to explain the observed inconsistency when
craving is used as a prospective predictor of
treatment outcome. For example, could a rela-
tively low level urge to smoke a cigarettean
urge that is well below what Kozlowski &
Wilkinson (1987) would call cravingstill
predict an eventual relapse as a function of its
duration rather than its intensity? To complicate
things more, duration may be the metric that
best predicts outcome, but only for a specic
subtype of smoker, whereas for others, intensity
may well be the metric of choice. Based on the
above reasoning, one might recommend the
elimination of a distinction between urges and
craving. Craving might be dened as a contin-
uum from none to very high.
Another possibility is craving could reect a
curvilinear relationship such as in the case of the
inverted U-curve of the classic Yerkes

Dodson
law. Low intensity craving may not predict loss of
control because they are perceived to be easy
to resist without necessarily using a coping re-
sponse. Moderate intensity craving may require
concerted use of coping skills to resist the temp-
tation to use. However, a moderate intensity of
urge could be the best indicator of successful
resistance to temptation because the urge trig-
gers an adaptive orientating response and mobi-
lizes effective coping skills to combat temptation
successfully (Niaura et al., 1989). A secondary
benet is that moderate urges could enhance
another important variableself-condence
(efcacy expectations)because the orientating
response results in successful mastery over the
urge/craving. Self-efcacy could be enhanced
even more by moderate urges versus low-level
urges. This is because the need to mobilize ones
coping skills would not be recognized for a low-
level urge, depriving the person of the oppor-
tunity to practice their coping skills and
strengthen self-efcacy expectations. Thus, in-
troducing the self-efcacy variable can drastically
change the predictive value of low vs. moderate
craving.
Consideration of self-efcacy expectations in
the comparison of low versus moderate intensity
craving might suggest that, paradoxically, low-
level craving could be more predictive of treat-
ment failure because it does not modify
self-efcacy or outcome expectations. Moreover,
the context of treatment may (paradoxically)
preclude the development of craving of medium
or strong intensity (especially when an addict is
living in the protected environment of an inpa-
tient treatment facility with few drug-related
cues, stressors and no availability/access). Lastly,
extremely high craving may overwhelm the indi-
vidual, resulting in the undermining of their self-
efcacy and leading to panic. Here, craving
would probably be prognostic of a poor out-
come, particularly in a context of drug-specic
cues and ready access to the drug of choice.
Alternatively, an individual with strong craving,
but who also has strong coping skills and ex-
tremely high self-efcacy, might be able to mobi-
lize all their resources to heroically resist
temptations and improve the prognosis of suc-
cessful outcomes. Thus, in the CSLT model,
coping skills and self-efcacy expectations can
strongly interact with low, medium or high crav-
ing to produce different outcomes. Path models
that examine the structural relationships among
cues, negative affect, self-efcacy, coping skills
and craving have in fact conrmed some of the
relationships described above (see Niaura,
2000). Structural modeling of the relationship
between these mediating mechanisms and out-
comes provides another tool to bridge interdisci-
low
low
med
high
med
high
high low
high
low
Coping
skills to
resist
craving
Self-efficacy
Craving
intensity
Craving intensity and duration by self-efficacy and coping skills
Craving
duration
S242 David B. Abrams
Figure 2. A structural model to illustrate the combinations of interactions among craving (intensity and duration) and self-
efcacy and coping skills. For example, craving of low intensity but very long duration might interact with low self-efcacy
so as to undermine the addicts ability to persist in the use of a good coping skills repertoire over time, resulting in relapse
(see text for full explanation).
plinary models and integrate process to out-
comes analyses.
Figure 2 provides a hypothetical structural
model of the possible combinations of interac-
tions that are possible from the relationship
among two dimensions of craving (intensity and
duration), each with three levels of measurement
(high, medium, low), and two cognitive-behav-
ioral factors (self-efcacy and coping skills). One
could envisage a hypothetical 3333232 (see
Fig. 1) matrix, where the mapping of interactions
rather than main effects would improve our
understanding of the circumstances (and other
variables) that could explain the inconsistent re-
lationship between craving and outcome. In this
example, the craving metric would result in nine
cells in the 333 matrix (of high, medium, low
intensity by short, medium or long duration).
Each of the nine values could be modulated by a
232 matrix consisting of the presence or ab-
sence of adequate coping skills and by having high
or low self-efcacy expectations. If a model of
craving that includes the interaction among crav-
ing (intensity and duration), coping skills and
self-efcacy improves the prediction of successful
outcomes, it could explain why any of these four
constructs, when used in isolation, is a poor
predictor of outcome. Of course, the challenge of
how to measure craving remains because craving
intensity, frequency and duration can vary dra-
matically across individuals and settings.
Implications for measures of craving
The complex interaction between biological,
psychological and socio-cultural mechanisms are
also differently emphasized in the various mea-
sures of craving. Craving is commonly measured
by self-report. Genetic and biological/
neurochemical processes play an important role
in determining the eventual level, sensitivity and
specicity of craving (Koob & LeMoal, 1997;
Kreek & Koob, 1998; Koob, 2000). Craving
may come to reect aspects of reinforcement,
dependence, tolerance and withdrawal after
acute or chronic deprivation. However, craving
can also depend on cognition or observable be-
havior, triggered by the presence of substance
specic cues, interoceptive cues or internal
states, and the situations previously associated
with use (i.e. set and setting). Craving can be
inuenced by perceived or actual availability of
the drug. Craving can occur under circum-
stances where the individual may not have used
the substance for a long time and therefore de-
pends more on distal memory mechanisms rather
Transdisciplinary concepts and measures of craving S243
than on more proximal biological/neuropharma-
cological factors associated with recent use and/
or withdrawal.
The subjective experience and measurement
of craving may also be strongly colored by socio-
cultural norms, role modeling and other contex-
tual variables that cue or shape individual
expectations of outcomes of use. MacAndrew &
Edgerton (1969) demonstrated that cultural
norms can strongly inuence behavior and sub-
jective experience. In some cultures, substance
abuse is circumscribed by religious rituals, and
the typical phenomena of loss of control is not
observed despite very heavy usage. Under such
contexts, intense craving may be labeled by
the culture as a normal urge, something to be
indulged with gay abandon. In our western cul-
ture, the special context and subculture of ado-
lescent behaviors (Quintero & Nichter, 1996)
and peer groups may create a similar subcultural
context where craving and indulgence are viewed
positively, entrained in memory during a critical
life-span developmental stage, thereby setting the
stage for later problems (Abrams & Niaura,
1987).
Although space does not permit a detailed
exploration of all the other factors that could
inuence the measurement and interpretation of
craving, a few selected issues are worth mention-
ing. Information processing mechanisms such as
selective attention, social desirability and opti-
mistic bias in perceptions of risk could modulate
craving. Investigators have suggested that crav-
ing could even exist without awareness or under
circumstances that Tiffany (1990) refers to as a
non-automatic (as opposed to automatic) pro-
cesses (Tiffany et al., 2000; Tiffany & Conklin,
2000). However, self-report may not be the only
way to measure craving as reected in standard-
ized cue reactivity paradigms that assess multiple
(physiological, cognitive, behavioral) response
modes (Abrams, 1986; Abrams et al., 1988;
Monti, Rohsenow & Abrams, 1995) or through
other non-verbal behaviors or behavioral tasks.
Sayette & Hufford (1995), for example, exam-
ined facial expression during cue exposure trials.
Innovations in imaging technology such as func-
tional magnetic resonance imaging (fMRI) and
positron emission tomography (PET) scanners
are also beginning to be used in cue reactivity
research paradigms.
Standardized cue

reactivity challenges under

controlled laboratory conditions provide a
powerful paradigm to examine the multi-
dimensional aspects of craving and to test the full
scope, boundaries and mediating and moderat-
ing mechanisms of the relationship between sub-
stance use cues and craving. This is because the
laboratory study of craving via cue exposure can
control for drug dose, time since exposure, in-
structional set, perceptions of drug availability
and contextual factors. However, these labora-
tory methods are limited in terms of their ecolog-
ical validity. The cue

reactivity paradigm has

been used to begin to map the parameters and
stimulus

response patterns of cue-elicited crav-

ing within and across drugs of abuse, examining
such factors as the role of visual and olfactory
cues (Niaura et al., 1998) or the relationship
between urges to smoke cigarettes and urges to
drink alcohol among alcoholic smokers (Abrams
et al., 1992). Laboratory cue exposure methods
and new highly specic pharmacological agents
(e.g. naltrexone, mecamylamine) can now be
used in behavioral pharmacology research to ex-
plore and isolate the precise mechanisms of ac-
tion of the neurobiology of craving (and their
interaction with interoceptive and environmental
cues).
Indeed, if craving in the laboratory can be
shown to reliably predict treatment success, then
the human experimental laboratory could be-
come a powerful tool to test new pharmacologi-
cal agents, identify their cognitive

behavioral
effects and link basic bench research, cognitive
neuroscience, animal studies and clinical trials
research. For example, one might be able to map
whether naltrexone blocks craving directly by
altering brain chemistry (e.g. mesolimbic do-
paminergic systems), or indirectly through re-
ducing the memory of the reward value of the
substance. The latter would require some actual
use of the previously abused substance while
taking naltrexone. Repeated trials with less re-
ward value would attenuate the individuals
learned expectations of positive outcomes (or
other memory systems) of substance use. If nal-
trexone, operated by attenuating the declarative
memory systems (hippocampus) or other sys-
tems previously associated with strong reward or
relief of aversive states, then new learning would
have to take place in the context of actual ex-
posure to the drug (White, 1996). One may also
be able to map different patterns for different
drugs of abuse, depending on which of the
memory systems were encodedincentive
S244 David B. Abrams
(amygdala), habit (caudate

putamen) or declar-
ative (hippocampal). White (1996) predicts, for
example, that cue-elicited craving and relapse
may be more difcult to extinguish for nicotine
versus other drugs of abuse because nicotine is
more strongly entrained in the memory systems
that are hardest to alter. Indeed, a recent study
in our laboratory of cue exposure treatment for
nicotine addiction was shown to be ineffective
(Niaura et al., 1999). Naturally, any of the mech-
anisms of neurobiological change noted above
would also interact with other important CSLT
self-regulatory mechanisms such as self-efcacy
expectations as previously described (Abrams &
Niaura, 1987).
Other researchers have pointed out that the
measurement of craving could be inuenced by a
strong relationship between craving, emotional
memory and mood states. Baker, Morse & Sher-
man (1987) suggested a bio-informational con-
ceptualization involving the processing of
emotional information. A related issue involves
how broad or narrow the denition of craving
should be. Craving could be measured as a de-
sire for drug use, the probability that a patient
would use the drug if it were readily available; or
it could include anticipation of the drugs rein-
forcing effects, and intention to use the drug
(Tiffany & Drobes, 1990). Consistent with the
idea of a multivariate approach to the measure-
ment of craving, craving can be represented by
responses that include behavioral, self-report,
physiological, cognitive and biochemical factors.
Cognitive style such as emotional blunting
including repression (i.e. selective attention) and
social desirability (Miller et al., 1995) could also
modulate the underlying construct of craving as
well as its verbal self-report. Cue exposure and
deprivation are known to effect cognitive re-
sources in smokers (Sayette & Hufford, 1994).
An individual may both experience little craving
and report no craving (due to selective inatten-
tion via the cognitive mechanism of repression/
denial) and then within seconds engage in
intensive drug use and loss of control. The ap-
propriate processing of emotional content and
physiological arousal could be impaired through
the chronic alteration of receptors, gene ex-
pression, social learning history or by acute
changes in attention allocation and distraction.
The relationship between craving, psychiatric co-
morbidities and the mechanisms that drive ob-
sessive

compulsive disorders is also relevant,

both at the neurochemical level and at the CSLT
and clinical treatment level (Anton et al., 1996).
Conclusion
The range of issues and the different levels of
self-regulation of behavior, from the cellular to
the socio-cultural, reect the richness and com-
plexity of both the construct of craving, as well as
the challenges for research on methods and
measurement, and the potential value of craving
when assessed under known and specic circum-
stances along with the other variables known to
modulate or interact with craving. While it is
clear from the brief examples in this paper that
biological, cognitive

behavioral and socio-

cultural factors can strongly inuence the self-
report of craving, a measurement model that can
simultaneously reect all the complex multivari-
ate contributions to craving has not yet been
fully articulated (Tiffany et al., 2000). Figure 1
reects a three-dimensional cubic space to illus-
trate that craving must be conceptualized and
measured across biological, psychological and
socio-cultural dimensions. Future research
should attempt to incorporate the multivariate
nature of craving into measures and methods
development. Measures should reect a multidi-
mensional rather than univariate set of compo-
nents. Based on what is now known about the
variables that inuence craving, from the mol-
ecular/cellular to the cognitive behavioral to the
socio-cultural/societal levels of analysis, a new
transdisciplinary conceptual modelwith a com-
mon language that can guide methods and
measurement developmentseems to be the
only way to make progress. A new conceptual
model must emerge from a true synthesis of
biopsychosocial perspectives, rather than the
multidisciplinary approach that adds one or two
methods or measures from another discipline but
falls short of full transdisciplinary integration
(Kahn & Prager, 1994). A critical set of ques-
tions and challenges remain to be addressed in
future research:
(1) Is the construct of craving useful and does
it add unique understanding, variance and
discriminatory power above and beyond
the other constructs that already exist? Is
craving part of the causal path to relapse, or
is it a post-hoc rationalizationan epiphe-
nomenon?
Transdisciplinary concepts and measures of craving S245
(2) Can a new integrative and interdisciplinary
theoretical model be constructed that can
place craving within a multi-dimensional
framework of measurement that incorpo-
rates the (i) biological; (ii) psychological;
and (iii) socio-cultural elements of the con-
struct over (iv) time?
(3) Is craving a dimensional construct that can
be evaluated on a continuum (either linear
or curvilinear), or is there a discrete
threshold or step function? Is it a combi-
nation of duration and intensity?
(4) How is craving best understood within the
biological framework of genetic susceptibil-
ity, the models of cognitive neuroscience,
and the relationships with the social learning
theory variables of mood regulation, expect-
ancy, observable behaviors and social cul-
ture?
(5) How does craving interact with self-efcacy,
coping skills and outcome expectations to
predict treatment outcomes? Can a measure
of craving help develop better diagnostic
tools and improve the tailoring of treatments
to individual differences or subgroups?
(6) Can human laboratory cue exposure models
that use craving as a dependent measure be
a useful tool to map the effects of new
pharmacological treatments, behavioral
treatments and identify process to outcome
path analyses of how treatments work? In
order for laboratory cue paradigms to be
useful, the assumption that craving is indeed
a sufciently strong proxy for actual behav-
ior outside the human laboratory must be
clearly demonstrated (i.e. ecological val-
idity).
(7) Can research on craving eventually be linked
to the broader context of cultural norms,
and could this in turn shed light on early use
among youth, especially during adolescence,
and the progression of some susceptible
users to dependence? The new tools avail-
able at the dawn of the 21st century (biologi-
cal, diagnostic, behavioral, social and
population science) may help, through the
transdisciplinary broadening of theory, to
shed light on these and other issues that will
advance our knowledge of craving in addic-
tive behaviors and inform improvements in
treatment and prevention of substance
abuse.
Acknowledgements
This work was supported in part by grant no.
AA11211 from the National Institutes for Al-
cohol Abuse and Alcoholism and the Robert
Wood Johnson Foundation Tobacco Etiology
Research Network. The author thanks Hazel
Ouellette and Barbara Doll for their invaluable
assistance with manuscript preparation.
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