A prospective examination of distress tolerance and early smoking lapse in adult self-quitters

“Similarly, initial data suggest that persistence on a CO2 challenge may be associated with early lapse to smoking (Brown et al., 2009).”

“…duration (R. A. Brown et al., 2002, 2009; Hajek, 1991; Hajek et al., 1987; cf. Steinberg et al., 2012), persistence on a CO2 challenge (R. A. Brown et al., 2002, 2009), and persistence on psychologically stressful and frustrating tasks (Brandon et al., 2003; R. A. Brown et al., 2009, 2002;…”

“…onto clinical outcomes has varied, with some suggesting that self-report measures are better indices of psychological functioning (e.g., Bernstein, Marshall, & Zvolensky, 2011) and others suggesting that behavioral measures better predict symptoms and other outcomes (e.g, R. A. Brown et al., 2009).”

“, 2006) and among behavioral indices of distress tolerance (Brown et al., 2009); minimal to low correlations have been documented between these two classes of distress tolerance factors (Marshall et al.”

“These findings were not replicated in a different sample of active smokers (211), although a significant relationship was found between low stress tolerance and early lapses when people were asked after testing to stop smoking for 28 days (211).”

“…to tolerate negative somatic and emotional states (distress intolerance) is associated with maladaptive avoidance behaviors, such as substance use (Brown et al. 2009), procrastination (Harrington 2005), risk taking (MacPherson et al. 2010), and avoidance of trauma cues (Vujanovic et al. 2011a).”

“Exclusion criteria for this study included variables contraindicated for the psychophysical testing or other study procedures, including (1) presence of an active infection; (2) significant arm or shoulder pain (due to potential interference with performance on study computer tasks); (3) history of myocardial infarcti…”

“This task has frequently been used as measure of physical distress intolerance (Brown et al., 2009; Hajek et al., 1987), with shorter durations of breath-holding indicating greater intolerance of physical distress.”

“This finding is consistent with the greater rates of treatment drop-out and relapse in smokers low in distress tolerance (Abrantes et al. 2008; Brown et al. 2009).”

“Empirical literature has indicated that lower distress tolerance is associated with a number of negative AOD use outcomes and psychopathology, including history of smoking cessation (Brown, Lejuez, Kahler, & Strong, 2002), smoking lapse and relapse (Brandon et al., 2003; Brandon, Vidrine, & Litvin, 2007; Brown et al.,…”

“Therefore, amelioration of the signs of early nicotine withdrawal using medications may prevent relapse to tobacco smoking when the urge to reinitiate nicotine use is the strongest (Abrantes et al., 2008; Brown et al., 2009; Shiffman et al., 2007).”

“…distress that predicts smoking lapses, but rather the degree to which an individual is able to tolerate discomfort (i.e., distress tolerance [DT], Brown, Lejuez, Kahler, & Strong, 2002; Brown et al., 2009) and to exhibit task persistence (Brandon et al., 2003; Quinn, Brandon, & Copeland, 1996).”

“Prospective studies have found that DI is associated with poor treatment outcomes for smoking cessation (Brown et al., 2009), drug dependence (Daughters, Lejuez, Kahler, et al., 2005), and depression (Williams, Thompson, & Andrews, 2013).”

“…associated with low selfreported and behaviorally-indexed DT across multiple nonclinical samples (Dennhardt and Murphy 2011; Anestis et al. 2012; Buckner et al. 2007; Ellis et al. 2010; Gorka et al. 2012), though this literature is not entirely consistent (Brown et al. 2009; Cummings et al. 2013).”

“For example, smokers who feel less able to tolerate adverse emotional experiences may be more prone to obtain relief by smoking in response to the experience, independent of their degree of tobacco withdrawal or even despite a desire to quit ( Brown et al., 2005 , 2009 ).”

“A 1 -week time frame was chosen to capture the initial volatile period during which most smoking lapses occur ( Brown et al., 2009 ; Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992 ) and to minimize the burden of daily laboratory assessments.”

“In the context of smoking cessation, early smoking lapse, typically defined as latency to the first instance of smoking (even a puff), is important because it is associated with an increased likelihood of return to regular smoking (i.e., relapse; Brown et al. 2005, 2009).”

“In contrast, those smokers with a lower threshold for tolerating such distress have shorter durations of smoking abstinence after attempting cessation (Brown et al., 2009; Hajek, Belcher, & Stapleton, 1987; West, Hajek, & Belcher, 1989).”

“…studies consistently finding a significant relation between low distress tolerance and adverse substance use outcomes (Abrantes et al., 2008; Brown et al., 2002; 2009; Daughters et al., 2005a, 2005b), including increased alcohol and marijuana use problems (Buckner et al., 2007; Bujarski et…”

“…with greater substance use frequency (Quinn, Brandon & Copeland 1996; Ali et al. 2013), shorter abstinence duration (Brown et al. 2002; Brandon et al. 2003; Daughters et al. 2005b), treatment dropout (Daughters et al. 2005a; Tull et al. 2013) and relapse (Brown et al. 2009; Strong et al. 2012).”

“These risk factors can theoretically be intervened upon to improve smoking cessation outcomes and include high anxiety sensitivity, low distress tolerance, anhedonia, and difficulties with emotion regulation (Brown et al. 2009; Assayag et al. 2012; Farris et al. 2015; Leventhal et al. 2015).”

“…that the tendency to experience thoughts and feelings as aversive has been associated with greater maladaptive behaviors, including substance use, aimed at eliminating those internal experiences (Brooks Holliday et al., 2016; Brown et al., 2009; Daughters et al., 2005; Hayes et al., 1996).”

“When examined separately, greater breath-holding and CO2 inhalation endurance were significantly related to risk of lapsing, though scores on the paced auditory serial addition task were not (Brown et al., 2009).”

“This work sits on the backdrop of the growing general recognition that how one responds to aversive internal or emotional states (perceived and/or actual) might play a central role in smoking processes and cessation behavior (e.g., Brown et al., 2009; Gifford & Lillis, 2009).”

“These classifications were also employed because they tend to capture the majority of early lapses/relapses and have demonstrated utility in predicting longer-term abstinence rates (e.g., Brown et al., 2001; Brown et al., 2009).”

“…of distress, but also one’s ability to tolerate both physical and psychological distress (i.e., distress tolerance) occurring in the context of withdrawal and early abstinence that predicts whether one succumbs to a lapse (Brandon et al., 2003; Brown et al., 2002, 2009; Quinn et al., 1996).”

“relapse (Brandon et al., 2003; Brown et al., 2009).”

“One study found that persistence on the Paced Auditory Serial Addition Test was not correlated with smoking relapse, although acute stress reactivity was not analyzed (Brown et al., 2009).”

“The PASAT has been used widely with substance use populations (Daughters et al., 2005; Vanderkaay and Patterson, 2006; Brown et al., 2009).”

“We failed to demonstrate correlations between the severity of anxiety and depression and the prevalence of specific stress coping strategies [39,40].”

“…withdrawal symptoms (Brown, Lejuez, Kahler, & Strong, 2002; Cook, Spring, McChargue, & Hedeker, 2004; Gilbert et al., 1998; Strong et al., 2009; Vujanovic & Zvolensky, 2009), which may interfere with very early cessation success (al’Absi, Hatsukami, Davis, & Wittmers, 2004; Brown et al., 2009).”

“For example, smokers with a greater ability to tolerate or withstand aversive somatic distress are less likely to lapse after a self-guided cessation attempt (27) whereas smokers with a lower threshold for tolerating such distress have shorter durations of smoking abstinence after attempting cessation (25,28,29).”

“, 2005), are associated with greater substance use frequency and poorer substance use treatment response (Ali et al., 2013a, 2013b; Billieux et al., 2010; Brown et al., 2009; Reese et al., 2019a; Strong, 2012; Tull et al., 2013), highlighting the value of developing and testing interventions that target these mechanis…”

“Prospective data suggest a 3 times higher risk of relapse among smokers with elevated versus low DI (Brown et al., 2009).”

“…Strong, & Brown, 2005) including pre-treatment attrition (MacPherson, Stipelman, Duplinsky, Brown, & Lejuez, 2008), shorter abstinence duration (Daughters, Lejuez, Kahler, et al., 2005), and greater lapse following smoking cessation (Brown, Lejuez, Kahler, & Strong, 2002; Brown et al., 2009).”

“…We use breath holding as an objective measures of distress tolerance because it has been shown to relate to outcomes in a variety of areas (Brown et al. 2002; Brown et al. 2009), and was shown previously to mediate the effects of an ACT-based treatment on weight control (Lillis et al. 2009).”

“Although it is evident that a low level of distress tolerance is predictive of early smoking lapse (Brandon et al., 2003; Brown et al., 2002, 2009), it is not as evident that this translates to the identification of individuals who, across multiple quit attempts over time, are consistently…”

“Literature supports the role of distress intolerance in the prediction of poor smoking cessation outcomes (Brandon et al., 2003; Brown et al., 2009), maintenance of anxiety psychopathology (Schmidt et al.”

“Distress tolerance has been associated with smoking lapse (Brown et al., 2005, 2009; Rohsenow et al., 2015) and decreasing distress tolerance, especially tolerance specifically related to withdrawal symptoms, may be a useful aim to incorporate into treatment in order to improve quit attempt…”

“, 2017), a latent cluster of internalizing disorders characterized by pervasive, dysregulated negative affect (Watson, 2005; Waszczuk, Kotov, Ruggero, Gamez, & Watson, 2017), and substance use disorders (Brown et al., 2009; Daughters et al., 2005; Hasan, Babson, Banducci, & Bonn-Miller, 2015; Strong et al., 2012), whe…”

“However, research has revealed that beyond distress severity, the degree to which an individual is able to tolerate distress (i.e., distress tolerance, Brown, Lejuez, Kahler, & Strong, 2002; Brown et al., 2009) also plays an important role in cessation success.”

“Due to the high interrelation between the breath-holding trials, as in past work (Brown et al., 2009), only the second trial was used.”

“Indeed, among studies assessing physical distress tolerance, individuals who are unable to tolerate aversive physical sensations are more likely to lapse following a quit attempt than those high in physical DT (10).”

“…carbon-dioxide-enriched air correlated with past early smoking lapse or relapse (Brown et al., 2002; Hajek, 1991; Hajek et al., 1987; West, Hajek, & Belcher, 1989), except in a study with low power (Zvolensky, Feldner, Eifert, & Brown, 2001) and predicted future smoking lapse (Brown et al., 2009).”

“This limitation is unfortunate, as there exists a growing recognition that how one responds to aversive internal or emotional states may play a pivotal role in smoking processes (Leyro, Zvolensky, Vujanovic, & Bernstein, 2008; Brown et al., 2009).”

“Other experimental and clinical work has found evidence that emotional suppression and lower levels of tolerance for emotional distress, which are two forms of emotional non-acceptance, are related to greater duration of smoking and shorter duration of abstinence during quit attempts (Brown, Lejuez, Kahler, & Strong,…”

“, DT) occurring in the context of withdrawal and early abstinence that predicts whether one succumbs to a lapse (Brandon et al., 2003; Brown, Lejuez, Kahler, & Strong, 2002; Brown et al., 2009; Quinn, Brandon, & Copeland, 1996).”

“…of persistence were positively correlated at pretreatment (r = .29, p .05) and at posttreatment (r = .43, p .05), and we standardized each and then summed them to create a general persistence variable for our main analyses (cf. Brown et al., 2009 with a different set of persistence measures).”

“For example, despite mixed results of studies linking smoking behaviors to intolerance of emotional states (Brandon et al., 2003; Brown et al., 2009; Sirota et al., 2010), the intolerance of respiratory discomfort (i.”

“This result is consistent with several human studies showing that substance users with low DT have a high rate of treatment dropout and relapse (Brown et al. 2002; Brandon et al. 2003; Daughters, Lejuez, Bornovalova, et al.2005a; Daughters, Lejuez, Kahler, et al. 2005b; Brown et al. 2009; Strong et al. 2012).”

“, 2002) and when examined prospectively (Brandon et al., 2003; Brown et al., 2009; Hajek et al., 1987).”

“Evidence suggests that both subjective and behavioral DT play a role in the development and maintenance of substance-use problems (Daughters et al., 2005; Buckner et al., 2007; Brown et al., 2009).”

“Specifically, there is a robust body of research on the effect of low DT on adult smoking outcomes (Brown et al., 2009; Leventhal & Zvolensky, 2015), demonstrating that the inability to persist through distress predicts early smoking lapse (Abrantes et al., 2008; Brown et al., 2009) and smoking…”

“, 2002) and experience greater craving and increased lapse risk during a quit attempt (Abrantes et al., 2008; Brown et al., 2009), compared to those with greater distress tolerance.”

“These techniques, which are drawn from Acceptance and Commitment Therapy, are described in Brown et al. (2009)a together with modestly promising results of a pilot test (n=16) of their application with smokers who had never been quit for longer than 72h following a quit attempt in the previous 10…”

“…(e.g., breath-holding, mental arithmetic, tracing geometric figures from the perspective of a mirror; Brown et al., 2002; Quinn, Brandon, & Copeland, 1996) and that the duration of persistence on these tasks prospectively predicts successful cessation (Brandon et al., 2003; Brown et al., 2009).”

“Higher anxiety sensitivity and negative affect avoidance may contribute to the higher relapse rates even among those who initially quit [14].”

“Indeed, there is a growing recognition that how one responds to aversive distressing states may be an important individual difference factor implicated in the maintenance of smoking and difficulties quitting.(21,22) For example, smokers with a greater ability to tolerate or withstand aversive somatic distress, relativ…”

“which are associated with failure to quit [10,27,28] and account for depression–substance use relations [29,30].”

“Research on mechanisms of cigarette smoking has supported the role of DT in relation to smoking status (e.g., Brandon et al., 2003; Brown et al., 2002; Quinn et al., 1996) and smoking cessation outcomes (e.g., Abrantes et al., 2008; Brown et al., 2009; MacPherson et al., 2008).”

“Smoking motivation might be a specific aim of psychological help for smokers who have difficulty tolerating distress, e.g. in Acceptance and Commitment Therapy (ACT; Brown et al., 2009), during which patients focus on developing the ability to accept disturbing feelings or physical sensations.”