by Michael D. Anestis, M.S.
Anyone who has tried to quit smoking will attest to the fact that doing so is extremely difficult. If this was not the case, companies that produce products aimed to help in the process would not be nearly as profitable as they are. Despite the likely universal agreement that quitting smoking is difficult, however, there are clear differences between individuals on exactly how hard the process is. For some people, quitting is cumbersome, but can be accomplished quickly without relapse. For others, relapse occurs soon after recovery if recovery happens at all. Because of these differences, a number of researchers have compiled data in studies attempting to determine what variables account for particular individuals' inability to persist in quit attempts, with the hope of then devising treatment techniques aimed at altering those variables and decreasing the difficulty of quitting. Less attention has been paid to another subsection of the population that is of equal importance: those who quit treatment prior to their first session. Quite obviously, pre-treatment attrition is unlikely to result in a positive outcome, so identifying who is most likely to quit treatment before it begins and initiating treatments capable of addressing their particular vulnerabilities would serve to increase the success rate of smoking cessation interventions.
A group of researchers - MacPherson, Stipleman, Duplinsky, Brown, and Lejuez (2008) - recently published a study that provided some insight into why certain individuals do not even make it to their initial treatment session after agreeing to take part in a smoking cessation program. The authors of this particular study noted that prior research had already demonstrated links between a variety of variables and pre-treatment attrition, including motivation to quit, younger age, lower education, weight concerns, and a history of psychotropic medication use (Ahluwalia et al., 2002; Copeland, Marin, Geiselman, Rash, & Kendzor, 2006; Curtin, Brown, & Sales, 2000; Schnoll et al., 2004; Woods et al., 2002). Less research, they noted, had been conducted examining the relationship between affective variables and pre-treatment attrition. Affective variables, unlike some of the variables listed above (e.g., age, education level, and history of psychotropic medication use), are excellent targets for psychosocial interventions and, as such, identifying affective variables relevant to pre-treatment attrition would provide an avenue for potential points of treatment.
Along these lines, the authors noted that depression symptoms have been linked to poorer treatment outcomes in individuals attempting to quit smoking (Kassel & Hankin, 2006). Surprisingly, however, depression symptoms have been shown to be unrelated to pre-treatment attrition (El-Khorazaty et al., 2007), meaning that this particular affective variable does not account for why some individuals do not even make it to their first session. As such, the authors designed a study examining a different set of affective variables - psychological and physical distress tolerance - as possible explanations for pre-treatment drop-out. Psychological distress tolerance, as defined in this particular study, is the degree to which an individual will continue with goal directed behavior in the presence of negative emotions. Physical distress tolerance, on the other hand, involves persistence in goal directed behavior in the presence of physical discomfort. Prior studies have linked low levels of distress tolerance to a variety of problematic outcomes, including increased severity of substance use (Quinn, Brandon, & Copeland, 1996), shorter time to relapse in individuals attempting to quit smoking or drugs (Brandon et al., 2003; Brown, Lejuez, Kahler, & Strong, 2002), in patient substance use treatment drop-out (Daughters et al., 2005), binge eating (Anestis, Selby, Fink, & Joiner, 2007), and non-suicidal self-injury (NSSI; Nock & Mendes, 2008).
In this study, the authors examined psychological and physical distress tolerance in a sample of 53 adult smokers signed up to participate in a randomized controlled trial of a behavioral activation treatment for smokers with depression. Psychological distress tolerance was measured using two computer tasks, each of which ask participants to engage in increasingly difficult tasks. Psychological distress tolerance is measured by how long participants persist on the task after being given the option to quit. Physical distress tolerance was measured by two tasks that required the participants to experience moderate levels of physical discomfort. In one task, participants were told to hold their breath and signal when they first felt discomfort. They were told to then continue holding their breath until they were no longer able to tolerate the discomfort. Physical distress tolerance was measured by the number of seconds between the first experience of discomfort and the point at which the participant quit the task. The second physical distress tolerance task - a cold pressor - required participants to place their arm in a container full of freezing water. Again, they indicated when they first felt discomfort, then persisted until they were unable to tolerate the sensation any longer, with physical distress tolerance measured by the number of seconds between the first feeling of discomfort and the time at which the participant quit the task.
The authors noted that prior research has indicated that women are more likely to smoke in an effort to reduce negative emotions (al'Absi, 2006) whereas men are more likely to smoke due to the physiological effects of nicotine (Perkins, 2001) and, as such, they anticipated that psychological distress tolerance would be a significant predictor of pre-treatment attrition for women whereas physical distress tolerance would be a significant predictor for men. Indeed, the results were consistent with their hypotheses. Women who dropped out of treatment prior to their first session were less able to persist in one of the psychological distress tolerance tasks than were both men and women in the treatment engagement group (individuals who took part in at least one treatment session). On the other hand, men who dropped out of treatment prior to their first session were less able to persist in either of the physical distress tolerance tasks than were men in the treatment engagement group.
Ultimately, these findings tell us several things. First, psychological distress tolerance appears to be a particularly important variable in determining which women are likely to drop out of smoking cessation treatment prior to attending their first treatment session. Second, physical distress tolerance appears to be a particularly important variable in determining which men are likely to drop out of smoking cessation treatment prior to attending their first treatment session. With respect to psychological distress tolerance, these findings have important treatment implications. Dialectical behavior therapy (DBT; Linehan, 1993) includes a component that is specifically designed to increase psychological distress tolerance skills. As such, it might be beneficial to include DBT distress tolerance skills in the initial stages of smoking cessation treatments - perhaps even during the initial assessment appointment - in an effort to decrease pre-treatment attrition. Similarly, the findings relevant to physical distress tolerance also have important treatment implications. Men with low physical distress tolerance might benefit from interoceptive exposure exercises. As Joye noted earlier this week in an article on interoceptive exposure, this particular treatment approach reduces anxiety regarding specific physical sensations and, when paired with aspects of cognitive therapy, can also help individuals to change the way they interpret and respond to those same physical sensations.
As is the case with any study, there were some important limitations to note when drawing conclusions regarding the data. First, the sample size was fairly small, which can limit the ability of researchers to statistically detect important between and within group effects. Additionally, the exclusion criteria were quite extensive. Individuals who were outside the age range (18-65 years of age), did not exhibit sufficient depressive symptoms, did not endorse motivation to quit smoking, met criteria for a DSM-IV disorder (other than depression), met criteria for any substance use or dependence (other than nicotine) in the past six months, were currently using psychotropic medication or psychotherapy, were unable to use the nicotine patch for physical reasons, or did not smoke enough cigarettes (at least 10 per day) or smoke long enough (at least one year) were excluded from the study. Obviously, this means that the sample was not necessarily representative of the population in general and, as such, it is unclear to what degree these findings apply to individuals who differ on those variables. The criteria were strict for a reason - to rule out these variables as better explanations for pre-treatment attrition - but future studies will need to change the exclusion criteria in order to increase the generalizability of the findings.
Ultimately, the take-home points from this particular study are quite clear. First, it appears that men and women may differ on their reasons for quitting smoking cessation treatment prior to the onset of treatment. Second, distress tolerance, whether distress refers to psychological or physical discomfort, appears to play a pivotal role in the vulnerability to pre-treatment attrition. Finally, because distress tolerance is a variable that can be directly addressed through empirically supported treatments, there is reason to believe that clinicians can help to increase the likelihood that vulnerable individuals will remain in treatment.
If you would like to learn more about distress tolerance, dialectical behavior therapy, or smoking cessation, we recommend the following products, all of which can be found through our online store:
- Cognitive-Behavioral Treatment of Borderline Personality Disorder
- Skills Training Manual for Treating Borderline Personality Disorder
- Dialectical Behavior Therapy for Binge Eating and Bulimia
- Cognitive-Behavioral Therapy for Smoking
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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