Exploring gender differences in tobacco cue-induced craving and heart rate variability in individuals with a tobacco use disorder

Introduction: Women face greater challenges quitting smoking and higher health risks than men, yet gender remains understudied in tobacco use disorder (TUD). This study investigates gender differences in subjective craving and heart rate variability (HRV) following tobacco cue exposure in abstinent individuals with a tobacco use disorder. Unlike heart rate, HRV reflects parasympathetic modulation, critical for understanding risk and resilience in addiction, but has rarely been studied as a cue-reactivity biomarker. Methods: Data from 41 men and 40 women who smoked cigarettes for more than 10 years were analyzed. Participants underwent a cue-exposure paradigm consisting of a relaxation phase (75 s), exposure to smoking videos (150 s) and pictures (150 s), and handling tobacco paraphernalia (120 s). Relief craving (the urge to use nicotine to alleviate negative emotions) and reward craving (the urge to use nicotine for its pleasurable effects) were measured pre/post cue exposure via the brief Questionnaire on Smoking Urges. HRV was continuously measured as root mean square of successive differences (RMSSD). Results: Cue exposure increased relief and reward craving and reduced HRV across participants (p < .001) without gender differences. Significant craving-HRV associations emerged only in women: those with higher exposure-induced reward craving showed the largest HRV reductions and recovery during paraphernalia handling (p < 0.01), whereas those with higher exposure-induced relief craving had smaller HRV declines and weaker recovery (p < 0.01). Conclusion: These findings reinforce HRV as a clinically relevant biomarker for tobacco cue reactivity and highlight gender differences in the autonomic nervous system's role in craving among individuals with TUD, suggesting stronger involvement in women.