Tolerating distress: why is it so difficult to quit smoking?

I remember how relieved I was when the smoking ban came into effect and the air in pubs and restaurants was no longer filled with cigarette smoke. I guess the aim of the policy was not only to protect the health of those of us who don’t smoke but also to encourage smokers to quit. Most of us understand that discontinuing an addictive habit is not that simple but what exactly is involved in quitting and why is it more difficult for some?

Most attempts to quit smoking, especially without help, result in failure (West, 2012). This is at least partly due to unpleasant withdrawal symptoms such as irritability, anxiety, low

Most of us are aware of the harmful effects of cigarette smoking. Image by Helgi Halldórsson from Reykjavík, Iceland - Dangers Of Smoking, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=33780867
Most of us are aware of the harmful effects of cigarette smoking. Image by Helgi Halldórsson from Reykjavík, Iceland – Dangers Of Smoking, CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=33780867

mood, problems with concentration and difficulty sleeping (Hughes, 2007). However, success also depends on an individuals characteristics such as their ability to tolerate discomfort (Sirota, Rohsenow, Dolan, Martin, & Kahler, 2013) and distress, i.e. unpleasant psychological states (Leyro, Zvolensky, & Bernstein, 2010). If we believe that we can withstand the withdrawal symptoms, then we are much more likely to be successful, especially if we also reappraise the experience and tell ourselves that it will be worth it in the end. Some research also suggests that people smoke in order to soothe anxiety and negative feelings in the absence of better ways of coping with these unpleasant emotional experiences (Leyro et al., 2010). Thus, the nicotine users becomes trapped in a vicious cycle where they smoke because they believe that a cigarette will soothe their negative feelings, and smoking  becomes a rewarding activity through its association with reduced distress. In other words, the less we can tolerate unpleasant feelings, the more rewarding smoking becomes.

Certain health problems, such as posttraumatic stress disorder (PTSD), can also make quitting smoking harder. This is due to the increased negative emotions, greater arousal, anger, and anxiety associated with such disorders. With regard to anxiety, a ‘fear of fear’ can also cause elevated worry, specifically worrying that stress/anxiety could have a harmful effect on our health (Kashdan, Zvolensky, & McLeish, 2008; Powers et al., 2016) therefore further diminishing an individual’s ability to cope (Leyro et al., 2010). Increased negative affect and severity of withdrawal symptoms also plague those with social anxiety who attempt to quit smoking (Buckner, Langdon, Jeffries, & Zvolensky, 2016). These additional difficulties are particularly important considering that those of us who have mental illness tend to smoke more and die earlier (Ziedonis et al., 2008). In addition, PTSD affects up to 30% of women who give birth (Grekin & O’Hara, 2014), and can therefore interfere with smoking abstinence among the new mothers addicted to nicotine.

Psychological therapy which teaches smokers to accept their internal feelings and sensations can considerably improve chances of quitting compared with standard intervention (quit planning, skills training, advice on pharmacotherapy, and social support for quitting) for smoking cessation (Bricker, Wyszynski, Comstock, & Heffner, 2013). For example, Acceptance and Commitment Therapy (ACT) encourages the individual to allow the thoughts, emotions and sensations that trigger smoking to come and go without attempting to control them. The resulting increased acceptance of these feelings allowed 23% of participants to remain smoke free up to 3 months after the therapy, compared with only 10% of those relying upon standard intervention alone. ACT also performed better than cognitive behavioural therapy (30% vs. 13% abstinence rate at 1 year) (Hernandez-Lopez, Luciano, Bricker, Roales-Nieto, & Montesinos, 2009).

It seems that the struggles with our own unpleasant feelings and the need to escape them play an important role in managing addiction: quitting smoking is not just about willpower or awareness of its harmful effect. Although this area needs a lot more research, it might be worth looking for help in increasing acceptance and mindfulness when battling withdrawal symptoms.

Post by: Jadwiga Nazimek

References:

Bricker, J., Wyszynski, C., Comstock, B., & Heffner, J. L. (2013). Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine & Tobacco Research, 15(10), 1756-1764. doi: 10.1093/ntr/ntt056

Buckner, J. D., Langdon, K. J., Jeffries, E. R., & Zvolensky, M. J. (2016). Socially anxious smokers experience greater negative affect and withdrawal during self-quit attempts. Addictive Behaviors, 55, 46-49. doi: 10.1016/j.addbeh.2016.01.004

Grekin, R., & O’Hara, M. W. (2014). Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev, 34(5), 389-401. doi: 10.1016/j.cpr.2014.05.003

Hernandez-Lopez, M., Luciano, M. C., Bricker, J. B., Roales-Nieto, J. G., & Montesinos, F. (2009). Acceptance and commitment therapy for smoking cessation: a preliminary study of its effectiveness in comparison with cognitive behavioral therapy. Psychol Addict Behav, 23(4), 723-730. doi: 10.1037/a0017632

Hughes, J. R. (2007). Effects of abstinence from tobacco: Valid symptoms and time course. Nicotine & Tobacco Research, 9(3), 315-327. doi: 10.1080/14622200701188919

Kashdan, T. B., Zvolensky, M. J., & McLeish, M. C. (2008). The toxicity of anxiety sensitivity and worry as a function of emotion regulatory strategies. Journal of Anxiety Disorders, 22, 429–440.

Leyro, T. M., Zvolensky, M. J., & Bernstein, A. (2010). Distress tolerance and psychopathological symptoms and disorders: a review of the empirical literature among adults. Psychol Bull, 136(4), 576-600. doi: 10.1037/a0019712

Powers, M. B., Kauffman, B. Y., Kleinsasser, A. L., Lee-Furman, E., Smits, J. A., Zvolensky, M. J., & Rosenfield, D. (2016). Efficacy of smoking cessation therapy alone or integrated with prolonged exposure therapy for smokers with PTSD: Study protocol for a randomized controlled trial. Contemp Clin Trials, 50, 213-221. doi: 10.1016/j.cct.2016.08.012

Sirota, A. D., Rohsenow, D. J., Dolan, S. L., Martin, R. A., & Kahler, C. W. (2013). Intolerance for discomfort among smokers: Comparison of smoking-specific and non-specific measures to smoking history and patterns. Addictive Behaviors, 38(3), 1782-1787. doi: 10.1016/j.addbeh.2012.10.009

West, R. (2012). Estimates of 52-week continuous abstinence rates following selected smoking cessation interventions in England.

Ziedonis, D., Hitsman, B., Beckham, J., Zvolensky, M., Adler, L., Audrain-McGovern, J., . . . Riley, W. (2008). Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research, 10(12), 1691-1715. doi: Pii 905756217

10.1080/14622200802443569

Save

Leave a Comment

Share This