Elsevier

Clinical Psychology Review

Volume 25, Issue 6, September 2005, Pages 713-733
Clinical Psychology Review

Distress tolerance and early smoking lapse

https://doi.org/10.1016/j.cpr.2005.05.003Get rights and content

Abstract

A significant percentage of smokers attempting cessation lapse to smoking within a matter of days and very few of these individuals recover to achieve abstinence. Current models of relapse devote insufficient attention to this phenomenon of early smoking lapse. Furthermore, studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. The authors argue that how one reacts to the discomfort of nicotine withdrawal is a more promising avenue of investigation than severity of withdrawal and that inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. Theoretical and clinical implications of distress tolerance in smoking cessation are discussed and the development of a specialized and novel behavioral distress tolerance treatment for early smoking lapsers is proposed.

Introduction

Cigarette smoking is the leading cause of death and disability in the United States, accounting for over 440,000 deaths in the United States every year (USDHHS, 2004), yet over 45 million adult Americans continue to smoke cigarettes every day (Control, 2004). This strong relationship between smoking and morbidity and mortality, and the clear benefits of successful cessation (USDHHS, 1990), have stimulated a great deal of interest in smoking cessation research. However, despite the desire of 70% of smokers to quit (Control, 1994), the 1 year quit ratio in the general smoking population is under 1% (Fiore, Novotny, Pierce, et al., 1989), and approximately 90–95% of smokers who quit on their own (Cohen et al., 1989) and 70–85% who attend treatment programs relapse within 1 year (Fiore, Bailey, & Cohen, 2000).

The selection hypothesis of smoking prevalence argues that smokers who are unable to quit successfully are likely to possess risk factors or characteristics that make it difficult to quit (Coambs et al., 1989, Hughes, 1995, Irvin & Brandon, 2000, Irvin et al., 2003). Although existing epidemiological evidence is equivocal regarding population level increases in levels of dependence (USDHHS, 2003), significant populations of at-risk, recalcitrant smokers remain (Augustson & Marcus, 2004) and efforts to develop treatments tailored to high-risk populations remain a national priority (USDHHS, 2003). In a review of available clinical trials conducted between 1975 and 1996, Irvin & Brandon (2000) documented a robust decrease in the abstinence rates achieved by intensive cognitive-behavioral smoking cessation interventions. Significant strides in smoking cessation ultimately may be found in the ability to develop specialized treatments that target the particular needs of subgroups of smokers, especially those who are at higher risk for relapse, rather than in expecting any single treatment approach to be a panacea (Brown, 2003a, Lichtenstein & Glasgow, 1992, Niaura & Abrams, 2002, Shiffman, 1993).

In the present article, we will highlight the importance of “early smoking lapse”, based upon the observation that a significant proportion of smokers attempting to quit will relapse within a matter of hours or days of their cessation attempt. In discussing the issues of smoking lapse and relapse, we use the term “lapse” to indicate an instance of smoking (even a puff of a cigarette) and “relapse” to indicate a return to one's baseline level of smoking. We present data suggesting that early smoking lapse following a cessation attempt is a common occurrence, and one that we believe has not received sufficient attention in the smoking treatment literature. Furthermore, we propose that the majority of smokers who lapse within a matter of hours or within days of a cessation attempt may be responding to a combination of physical and psychological discomfort to the nicotine withdrawal syndrome (Hughes, Higgins, & Hatsukami, 1990) that reliably accompanies the initial stages of smoking cessation. These individuals may be characterized by their reduced ability to tolerate the physical discomfort and negative affect associated with nicotine withdrawal and by their lack of persistence in the face of this discomfort.

Baker, Piper, McCarthy, Majeskie, and Fiore (2004) have recently offered a reformulated model of negative reinforcement in addiction, proposing that negative affect is the “motivational core” of the withdrawal syndrome. We agree with this model, and further posit that there are individual differences in how smokers respond to negative affect, and it is these responses in the face of negative affect that determine who lapses and who maintains abstinence. We present data supporting these assumptions and propose that a specialized behavioral treatment for these “early smoking lapsers” is indicated, and would feature components to assist them in learning skills to increase their ability to tolerate discomfort and negative affect and to persist despite experienced discomfort at the task of remaining abstinent from smoking.

Section snippets

Relapse prevention and the significance of early smoking lapse

In light of high smoking relapse rates (Brownell et al., 1986, Garvey et al., 1987, Hunt & Bespalec, 1974), Marlatt and Gordon's (1985) social learning-based (Bandura, 1977), relapse prevention model has stimulated considerable research. The relapse prevention model proposes that an individual's ability to cope successfully with situational factors that may precipitate relapse, and to develop a more balanced lifestyle are the key factors that determine the probability of smoking relapse.

Withdrawal symptom severity

Given the emergence of both physiological and psychological symptoms that occurs within hours of nicotine deprivation (Hughes et al., 1990), severity of nicotine withdrawal might be expected to be the strongest predictor of early lapse and subsequent relapse. Since the 1988 Surgeon General's report affirmed the role of nicotine dependence in the initiation and maintenance of cigarette smoking (USDHHS, 1988), nicotine withdrawal has been an emerging focus of scientific investigation (Hughes, 1992

Distress tolerance and early smoking lapse

Emerging evidence regarding the construct of distress tolerance suggests that it is not just the severity or intensity of nicotine withdrawal, but also how an individual responds to discomfort and distress that predicts early smoking lapses. Early lapsers may be characterized by a tendency towards negative affect during nicotine withdrawal and also an inability to tolerate negative affect. We have previously referred to this combination as a “double whammy” with regard to early lapse in

Development of a novel smoking cessation treatment for early smoking lapsers

Given that the cognitive-affective response to distress may be at the core of early smoking lapse, it is crucial to develop novel treatment strategies for smokers with a history of repeated early lapses that helps smokers tolerate the short-term discomfort associated with acute cessation. In the following section, we outline the development of a “distress tolerance treatment”. We expect that any such treatment would include components of standard smoking cessation treatment, both behavioral and

Summary and conclusions

Recent evidence suggests that a significant percentage of individuals attempting smoking cessation lapse to smoking within a matter of days, and that very few of these individuals are able to recover to achieve abstinence from smoking. Current models of relapse devote insufficient attention to this phenomenon of early lapse. Studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. We believe that how one reacts

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    This paper was partially supported by a National Cancer Institute research grant awarded to Dr. Brown (CA88297) and by National Institute on Drug Abuse research grants to Drs. Brown (DA017332), Lejuez (RO1 DA15375) and Zvolensky (DA16307-01 and DA016227).

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