Distress Tolerance and Smoking Cessation

ABSTRACT
Tobacco addiction is a costly and often fatal problem. Even with counseling and nicotine replacement therapy,
most smokers relapse following a quit attempt. For many smokers, cigarette smoking is provoked by affective
distress. The ability to cope with this distress and remain abstinent may depend on one's level of distress
tolerance, which is the ability to persist in a goal-directed activity while experiencing physical or affective
discomfort. However, a gap in knowledge exists regarding the neural mechanisms that underlie distress
tolerance. Identifying these neural mechanisms and understanding individual differences in distress tolerance
holds promise for the development of new therapies and the improvement of cessation success through
personalized interventions.
Past research has shown that cigarette cravings and other forms of affective distress activate the insula,
which may be the neural hub that connects the awareness of affective distress to cognitive control regions that
determine the subsequent behavioral response (e.g., smoking a cigarette to relieve cravings). However, there
is a significant gap in knowledge concerning whether insula connectivity underlies real-world distress tolerance
behavior in the service of smoking cessation. Lab-based measures of distress tolerance provide standardized
comparisons across individuals and could be used to identify smokers who would most benefit from
interventions. A complementary approach, ecological momentary assessment, can capture temporal
relationships among affective distress, craving, and smoking as they occur in smoker's daily lives, in real time.
The goal of this research is to test the predictive validity of lab-based measures of distress tolerance against
the real-world stress/smoking relationship, and to identify neural differences within smokers that relate to
distress tolerance and could predict quit outcomes (i.e., relapsed vs nonrelapsed).
To address this gap in knowledge, we will investigate three aims: Aim 1) Associate lab measures of
distress tolerance to insula connectivity. Aim 2) Relate lab measures of distress tolerance with real-world
stress and smoking using ecological momentary assessment. Aim 3) Explore how insula connectivity relates to
real-world stress and smoking. By providing clear evidence of how distress tolerance, brain connectivity, and
daily stress relate to quit outcomes, this study will greatly increase our understanding of why some smokers
succeed in quitting while others relapse. This research will be generalizable to other drug addictions and
psychiatric conditions that are exacerbated by physical or affective distress. Successful completion of this
study will inform the development of personalized smoking interventions, as well as identify neural
mechanisms that can be targeted by novel therapeutic techniques.

Grant Number: 5R01DA048948-06
NIH Institute/Center: NIH
Principal Investigator: Merideth Addicott