Elsevier

Preventive Medicine

Volume 47, Issue 2, August 2008, Pages 215-220
Preventive Medicine

Physical activity as a strategy for maintaining tobacco abstinence: A randomized trial

https://doi.org/10.1016/j.ypmed.2008.05.006Get rights and content

Abstract

Objectives

For smoking cessation, physical activity (PA) may help manage withdrawal symptoms, mood, stress, and weight; yet studies of PA as an aid for smoking cessation have been mixed. This study examined: (1) the impact of an extended relapse prevention program on increasing moderate to vigorous PA (MVPA) in adults enrolled in a tobacco cessation treatment trial; (2) whether changes in MVPA were associated with sustained abstinence from smoking; and (3) mechanisms by which MVPA may support sustained abstinence from smoking.

Methods

In a randomized controlled trial conducted from 2003–2006 in San Francisco, California, 407 adult smokers received a 12 week group-based smoking cessation treatment with bupropion and nicotine patch with the quit date set at week 3. At week 12, participants were randomized to no further treatment or to 40 weeks of bupropion or placebo with or without an 11-session relapse prevention intervention of which 2 sessions (held at weeks 16 and 20) focused on PA. Participants receiving the PA intervention (n = 163) received a pedometer, counseling to increase steps 10% biweekly towards a 10,000 steps/day goal, and personalized reports graphing progress with individualized goals. The International Physical Activity Questionnaire assessed weekly minutes of MVPA at baseline and weeks 12 and 24. Sustained abstinence from tobacco at week 24 was validated with expired carbon monoxide.

Results

In a repeated mixed model analysis, intervention participants significantly increased their MVPA relative to control participants, F(1,475) = 3.95, p = .047. Pedometer step counts also increased significantly, t(23) = 2.36, p = .027, though only 15% of intervention participants provided 6 weeks of pedometer monitoring. Controlling for treatment condition, increased MVPA predicted sustained smoking abstinence at week 24, odds ratio = 1.84 (95% CI: 1.07, 3.05). Among participants with sustained abstinence, increased MVPA was associated with increased vigor (r = 0.23, p = .025) and decreased perceived difficulty with staying smoke-free (r =  0.21, p = .038).

Conclusion

PA promotion as an adjunct to tobacco treatment increases MVPA levels; changes in MVPA predict sustained abstinence, perhaps by improving mood and self-efficacy.

Introduction

Tobacco use is the leading preventable cause of death in the United States (CDC, 2005). Only 3% to 5% of smokers who try to quit unaided achieve prolonged abstinence at 6 to 12 months (Hughes et al., 2004). Even with evidence-based smoking cessation treatments, relapse is common (Piasecki, 2006), often in response to mood changes (Shiffman and Waters, 2004), withdrawal symptoms (Piasecki et al., 2000), weight gain (Borrelli et al., 2001), and cravings (Killen and Fortmann, 1997).

Physical activity (PA) may be useful in addressing the physiological and psychological causes of relapse to smoking (Bock et al., 1999, Ussher et al., 2001). A systematic review of 12 studies comparing a bout of exercise with a passive condition reported a positive effect for reducing cigarette cravings, negative affect, withdrawal symptoms, and smoking behavior (Taylor et al., 2007). Two additional studies concluded the effect of PA was irrespective of the intensity level (moderate vs. vigorous). Further, the mechanism by which PA reduces desire to smoke and nicotine withdrawal symptoms is distinct from simple cognitive distraction (Daniel et al., 2006).

Though most people who quit smoking will gain less than 10 lb (Williamson et al., 1991), weight gain concerns are predictive of smoking initiation, reluctance to quit smoking, and smoking relapse (Gritz and Crane, 1991, Klesges et al., 1989, Perkins et al., 1995). For managing weight gain associated with quitting smoking, clinical practice guidelines recommend PA, rather than dieting (Fiore et al., 2000). In general practice, PA is an effective strategy for weight gain prevention (USDHHS, 1996).

Adults who smoke tend to be less physically active than nonsmokers (Kaczynski et al., 2008). Unger (1996) observed that adults preparing to quit smoking exercised more than smokers in the earlier stages of change. Further, a significant positive association has been found between one's self-efficacy for quitting smoking and self-efficacy for maintaining PA (Boudreaux et al., 2003).

The evidence for PA as a strategy for supporting smoking cessation, however, is not strong. A Cochrane review of 11 randomized controlled trials examining PA as a smoking cessation strategy concluded that while exercise promotion did not appear to harm smoking cessation efforts, there was limited evidence that it helped (Ussher, 2005). Only one of the 11 trials found evidence for PA aiding smoking cessation at long-term follow up (Marcus et al., 1999). The program was highly structured, supervised, and promoted PA of vigorous intensity. A follow up study that promoted engagement in moderate PA and used more of a home-based approach failed to find an effect for long-term cessation relative to a standard cognitive behavioral cessation program (Marcus et al., 2005). In the Cochrane review, only two studies reported changes in PA, limiting our understanding of the feasibility of smokers making changes in their tobacco use and PA patterns concurrently (Ussher, 2005). A follow up study reported no long-term effect of a PA intervention on tobacco abstinence, but also reported no difference in PA levels between the intervention and control conditions (Ussher et al., 2007).

When quitting smoking, the timing of the PA program and the intensity of PA promoted (vigorous vs. moderate) may be important. Moderate or “lifestyle” exercise programs may offer greater efficacy and practicality for dissemination (Dunn et al., 1998, King, 1998), greater participant adherence (King et al., 1995), and greater appeal to sedentary smokers (Ussher et al., 2001). The current study examined: (1) the impact of an extended relapse prevention program on increasing moderate to vigorous PA (MVPA) in adults enrolled in a tobacco cessation treatment trial; (2) whether changes in MVPA were associated with sustained abstinence from smoking; and (3) mechanisms by which MVPA may support sustained abstinence from smoking. Hypothesized mechanisms included enhanced psychological states, reduced withdrawal symptoms, improved health functioning, reduced weight gain, and greater motivation and self-efficacy to stay tobacco-free. Baseline correlates of PA also were examined with sample demographic and tobacco use characteristics.

Section snippets

Participants

Participants were 407 adults who smoked at least 10 cigarettes daily for 5 or more years and smoked within 30 min of awakening. The study, conducted in the San Francisco Bay Area, recruited smokers interested in quitting via direct mail and media advertisements. Recruitment spanned February 2003–December 2005 with the 24 week assessments completed in June 2006. The study was limited to English speakers. Exclusion criteria included contraindications to bupropion use (e.g., elevated seizure

Participant baseline characteristics

The sample was 61% male with a mean age of 40.7 years (SD = 9.8). Race or ethnic identification was Caucasian (71%), African American (8%), Asian/Pacific Islander (6%), Hispanic (3%), multiracial (10%), and other (2%). Most participants (74%) had attended some college; 45% held at least a bachelor's degree; 72% were employed. The measured BMI of the sample averaged 26 (SD = 5) for men and 26 (SD = 6) for women at baseline; 54% of the men and 47% of the women were classified as overweight or obese.

Discussion

The current study examined promotion of PA as part of an extended relapse prevention program for smoking cessation. The PA component was brief (2 sessions), individualized, encouraged self-monitoring with a pedometer, and promoted gradual increases in lifestyle MVPA. As hypothesized, we found significant increases in MVPA from baseline to week 24 among participants receiving the PA intervention, whereas MVPA among control participants declined. Among intervention participants who did their

Acknowledgments

This work was supported by the National Institute on Drug Abuse (#R01 DA015732, #K05 DA016752, #K23 DA018691 and #P50 DA09253) and the State of California Tobacco-Related Disease Research Program (#13KT-0152). The authors have no financial interests related to the material in the manuscript. The study was presented orally at the Annual Meeting of the Society of Behavioral Medicine in San Diego, CA on March 28, 2008. We thank Kevin Ahern for his assistance with data management.

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