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Negative affect, emotional acceptance, and smoking cessation.

Abstract--This article describes recent theoretical developments and empirical findings regarding the role of negative affect (NA) and emotion regulation in nicotine dependence and smoking cessation. It begins with a review of affect-based models of addiction that address conditioning, affect motivational, and neurobiological mechanisms and then describes the role of NA and emotion regulation in the initiation and maintenance of cigarette smoking. Next, the role of emotion regulation, coping skill deficits, depression, and anxiety sensitivity in explaining the relationship between NA and smoking relapse are discussed. We then review recent models of affect regulation, including emotional intelligence, reappraisal and suppression, and emotional acceptance, and describe implications for substance abuse and smoking cessation interventions. Finally, we point out the need for further investigations of the moderating role of individual differences in response to NA in the maintenance of nicotine dependence, and controlled randomized trials testing the efficacy of acceptance-based interventions in facilitating smoking cessation and relapse prevention.

Keywords--acceptance, distress tolerance, emotion regulation, interoceptive exposure, mindfulness, nicotine dependence

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According to the negative affect (NA) model of tobacco use disorder, the initiation and maintenance of nicotine dependence is in part determined by a tendency to experience negative affective states combined with difficulty tolerating emotional distress, affect regulation deficits, and expectations that cigarette smoking will help reduce such aversive states (Brown et al. 2005; Baker et al. 2004; Kenford et al. 2002). Since the first author initially reviewed the literature on the relationship between affect regulation, cigarette smoking, and nicotine dependence almost two decades ago (Carmody 1989), important advances have occurred in the study of the role of NA in the initiation and maintenance of chemical dependence (Baker et al. 2004; Carver 2004; Larsen & Prizmic 2004; Brandon 1994; Stasiewicz & Maisto 1993). Similarly, methodological advances such as experience sampling (Tennen, Affleck & Armeli 2005) and assessment of stress hormones (Marinelli & Piazza, 2002) have allowed for more precise measures of day-to-day affective states in relation to substance use (Shiffman & Waters 2004). In this article, we explore how recent empirical and theoretical advances in the study of emotion regulation have enhanced our understanding regarding the role of NA in the initiation and maintenance of tobacco use, and describe implications for the treatment of substance abuse and nicotine dependence.

NEGATIVE AFFECT AND TOBACCO USE

The relationship between NA and tobacco use is complex, involving bidirectional causal, contextual, and predisposing factors, and individual differences in response to emotional distress that are difficult to disentangle (Carmody 1989). Studies have yielded inconsistent findings, reflecting the complex relationship between smoking and NA, and the influence of multiple moderator variables and mediating factors on the smoking-affect relationship (Kassel, Stroud & Paronis 2003). A number of individual difference variables, including neuroticism, trait anxiety, impulsivity, gender, and negative affectivity appear to influence the relationship between NA and tobacco use (Gilbert 1995).

Definition of Negative Affect

NA is defined as the experience of acute emotional states involving anger, sadness (depression), and/or fear (anxiety). Negative affective states are experienced as unpleasant, unwanted, or aversive, and typically motivate efforts to terminate or avoid them. The specificity versus generality of NA has been debated. For example, Watson, Clark, and Tellegen (1988:1063) have defined NA as a "general dimension of subjective distress and unpleasurable engagement that subsumes a variety of aversive mood states, including anger, contempt, disgust, guilt, fear, and nervousness, with low NA being a state of calmness and serenity." According to Watson and colleagues (1988), the construct of NA, then, does not involve differentiation among various types of negatively-valenced emotional states. In contrast, the discrete emotions approach (Izard 1993) focuses on the characteristics and functions of individual emotions as sources of motivation rather than categorizing emotions according to general dimensions such as positive-negative or pleasant-unpleasant. Individuals with psychiatric disorders such as recurrent major depression are prone to experience more frequent and severe episodes of NA.

Affect-Based Models of Addiction

Attempts to explain the relationship between NA and addictive behavior, including chronic tobacco use, have relied primarily on conditioning, motivational, and neurobiological models of addiction. These are described briefly below.

Conditioning models. A number of models of addiction focus on the notion that negative affective states can become conditioned stimuli that elicit conditioned drug-related responses (Coffey et al. 2006; Carmody 1989). For example, according to the two-factor theory of emotional conditioning and avoidance learning (Stasiewicz & Maisto 1993), compulsive drug use is thought to be maintained by avoidance of conditioned aversive emotional stimuli. Most conditioning models include both external and internal cues (Niaura et al. 1988). However, in recent years, there has been increasing interest in internal or interoceptive (emotional and physiological) cues in relation to drug craving and relapse, particularly when the drug use is linked to attempts to avoid or control negative affective states (Zvolensky, Schmidt & Stewart 2003).

Affective (negative reinforcement) model of drug motivation. The stress and coping (Wills & Shiffman 1985) and self-medication models (Khantzian 1997) both involve negative reinforcement. According to these models, the addicted individual uses drugs to escape or avoid emotional suffering. The recently revised negative reinforcement model of addiction posits that escape or avoidance of NA is the primary motivation for addictive drug use (Baker et al. 2004). The motivation to escape or avoid NA is assumed to occur outside the awareness of the addicted individual unless or until the NA becomes so intense that it enters consciousness (Baker et al. 2004). According to this model, drug motivation is thought to increase in response to stress because drugs reduce the experience of stress, and an association develops between the NA involved in withdrawal and the affective distress related to stressful events. The internal affective cues associated with withdrawal and stressful events predispose the individual to continued drug use. In addition, the history of negative reinforcement associated with drug use leads to the development of a positive affective response to drug cues and use.

Neurobiological mechanisms. The neurobiological mechanisms involved in the initiation and maintenance of nicotine addiction overlap with many of those involved in the regulation of NA (Kreek & Koob 1998). This is not surprising since nicotinic cholinergic circuits are involved in a range of cognitive processes involved in the experience of emotion, including attention, memory, reward, and perception (Lucas-Meunier et al. 2003). Nicotine stimulates the release of acetylcholine, serotonin, and pituitary hormones (e.g., b-endorphin, vasopressin, prolactin, ACTH, and growth hormone) and acts on the adrenal medulla peripherally to release epinephrine (Pomerleau & Pomerleau 1990; Pomerleau 1986b). It also stimulates the release of dopamine and norepinephrine from nerve terminals throughout the brain and release of norepinephrine by means of its direct action at the peripheral noradrenaergic terminals of the sympathetic nervous system (Balfour 1982). Nicotine's action on cholinergic receptors imitates the effects of acetylcholine at low doses, but blocks transmission after initial agonistic activity at higher doses. Thus, the overall effect of chronic high doses of nicotine is to produce a biphasic reaction characterized by initial stimulation followed by a depressant or blocking effect (Pomerleau 1986a). Over the past two decades, a number of investigations have shown that the cholinergic mechanisms stimulated by nicotine influence learning, memory, alertness, and alleviation of dysphoric mood (Balfour & Ridley 2000; Pomerleau & Rosencrans 1989).

In recent neuroimaging studies, the effects of nicotine have been observed on emotional information processing systems in the brain (Gilbert et al. 2005). The results of these studies suggest that nicotine's effects on different brain structures are dependent on task demands and other situational factors, smoker status, and individual differences in genetically-influenced personality characteristics (McClernon & Gilbert 2005). In addition, studies of the effects of nicotine on event-related potential (ERP) responses indicate that nicotine influences affective information processing and attention (Carretie et al. 2001). Recent data from studies of nicotine's effects on ERP responses to emotional pictures suggest that nicotine may be associated with a shift in information processing bias away from negative stimuli and toward more positive stimuli (Gilbert et al. 2005).

Negative Affect and Stages of Tobacco Use

NA has been shown to play a role in the initiation and maintenance of tobacco use as well as in relapse following quit attempts. We briefly describe the role of NA in each of these stages of nicotine addiction below.

Negative affect and initiation of tobacco use. Emotional experience and tobacco use have overlapping genetic and neural bases, and are both affected by psychological, social, environmental, and cultural factors (Kassel et al. 2003). A number of recent studies have shown the important role of stress and NA in the onset of tobacco use among adolescents and in the progression from experimentation to regular use and establishment of nicotine dependence (Kassel et al. 2003; Brown et al. 1996). Affective distress and stressful life events appear to be associated with the transition from experimental to regular smoking in adolescents (Orlando, Ellickson & Jinnett 2001). However, the relative contribution of NA versus externalizing behavior in the development of smoking behavior in adolescents remains to be determined (Whalen et al. 2001). In prospective longitudinal studies (e.g., Ferdinand, Blum & Verhulst 2001), emotional distress has been shown to be linked to smoking initiation. However, longitudinal and cross-sectional studies do not consistently support the notion that NA plays a significant role in the initiation of tobacco use (Kassel, Stroud & Paronis 2003). In contrast, the evidence for the relationship between externalizing disorders and smoking initiation appears to be much stronger (e.g., Ryan 2001).

Negative affect and maintenance of nicotine addiction. Each of the theories described above (i.e., conditioning, motivational, and neurobiological) have contributed to our understanding of how NA serves to maintain tobacco use and nicotine dependence. Brandon (1994) reviewed the empirical evidence showing that use of tobacco to cope with negative affective states is an important factor in maintaining nicotine addiction. Despite the lack of consistent empirical support for the impact of smoking on NA, most smokers believe that smoking helps them cope with stress and emotional distress (Brandon & Baker 1991). Models that focus on direct effects of smoking on NA and visa versa are giving way to more comprehensive approaches that incorporate moderating individual difference factors such as coping styles and psychopathology as well as mediating variables such as attention and other cognitive processes (Kassel, Stroud & Paronis 2003). Gilbert's (1995) Situation x Trait Adaptive Response model is an example of this approach. The complexity of the relationship between NA and maintenance of smoking has been demonstrated in studies focusing on depression which suggest bidirectional causal processes and common factors (e.g., neuroticism) that predispose individuals to both depression and nicotine dependence (Breslau, Kilbey & Andreski 1993; Hall et al. 1993; Kendler et al. 1993).

Smoking relapse. The role of NA in smoking relapse has been studied extensively (Kassel, Stroud & Paronis 2003). Stress and NA have been shown to be associated with smoking relapse in cross-sectional and longitudinal studies (Shiffman & Waters 2004; Kenford et al. 2002). Below we describe the relationship between NA and smoking relapse with regard to nicotine withdrawal, coping deficits, depression, and anxiety sensitivity.

Nicotine withdrawal. Emotional distress experienced at the beginning of a quit attempt as well as that experienced as a part of nicotine withdrawal during early abstinence are both predictive of poor outcomes (Kinnunen et al. 1996). Determining the role of NA in smoking relapse is challenging due to confounds in the measurement of affective functioning during active smoking periods (which could mask symptoms) or post-cessation withdrawal. According to one hypothesis, NA is associated with smoking relapse because of its impact as a symptom of nicotine withdrawal (Piasecki et al. 2003). Although nicotine produces relatively mild psychoactive effects, recent research suggests that nicotine withdrawal results in decreased brain reward function that is comparable in magnitude and duration to other major drugs of abuse (Epping-Jordan et al. 1998). This increased reward threshold results in the subjective experience of NA, anxiety, irritability, and craving. These negative affective states, including irritability, dysphoria, and anxiety, are among the most common symptoms of nicotine withdrawal (Hughes, Higgins & Hatsukami 1990).

Coping deficits. Impairments in the capacity to manage stress may increase risk for smoking relapse (Shiffman & Waters 2004; Carmody 1993). In early studies of coping and relapse, Shiffman, Read and Jarvik (1985) found an association between depression and lack of success of behavioral coping strategies. Matheny and Weatherman (1998) found that the presence of "stress coping resources" predicted abstinence maintenance in former smokers who had completed a national smoking cessation program. In a study of stress and smoking relapse, Abrams and colleagues (1987) found that ex-smokers who were successful in remaining abstinent were rated as more skillful in coping with stressful situations than those subjects who relapsed. Kamarck and Lichtenstein (1988) showed that maintenance of abstinence was associated with a larger repertoire of affect regulation coping strategies. These findings support the notion that effective regulation of NA is an important determinant of smoking cessation and maintenance of abstinence. They also suggest that training in adaptive stress management coping skills should facilitate smoking cessation and relapse prevention.

Depression. Smokers with a history of major depressive disorder (MDD) experience more NA, withdrawal symptoms, and greater mood disturbance during quit attempts (Hughes 1999; Ginsberg et al. 1995). However, the results of a recent meta-analysis (Hitsman et al. 2003) suggested that lifetime history of major depression may not be an independent risk factor for smoking cessation failure. Interestingly, depressive symptoms at the time of the quit attempt are more closely linked to outcome than previous depression (Japuntich et al. 2007). There is preliminary evidence that smokers with a history of more than one episode of MDD may be more likely to experience more severe symptoms of depressed mood and more difficulty quitting (Haas et al. 2004).

Anxiety sensitivity. Anxiety sensitivity (AS) is an individual difference factor that involves fear of physical, mental, and publicly observable anxiety-related experiences (Reiss & McNally, 1985). Individuals with elevated AS are often fearful of anxiety-related symptoms and bodily sensations (Taylor et al. 1992), respond with fear and anxiety when confronted with relevant interoceptive cues (Barlow 2002), and cope with anxiety-related states by trying to avoid them (Feldner, Zvolensky & Leen-Feldner 2004). AS has been shown to be predictive of an increased chance of early smoking lapse during a quit attempt (Brown et al. 2001) and the expectation that smoking will alleviate NA (Zvolensky et al. 2004). AS may be related to emotional sensitivity processes associated with smoking. It has been hypothesized that AS increases attention to feared physiological sensations by means of heightened vigilance (Hunt, Keogh & French 2006). This heightened attention may increase the salience of NA cues that trigger affective motivational processes involved in addictive behavior. According to one theory, smokers with elevated AS may smoke in order to cope with anxiety-related symptoms because they perceive interoceptive stimuli as more aversive (Zvolensky Schmidt & Stewart 2003). AS has been shown to be associated with motivation to smoke to reduce NA and low levels of confidence in remaining abstinent when emotionally distressed (Zvolensky et al. 2006). AS appears to be related to the absence of emotional acceptance or distress tolerance skills.

RECENT ADVANCES IN MODELS OF AFFECT REGULATION

An understanding of the relationship between NA and tobacco use is incomplete without consideration of individual differences in affect regulation coping responses as important mediating and moderating factors. In our previous review (Carmody 1989: 331), we described the regulation of negative affective states as "any attempt to cope with stress or alleviate negative mood states by using pharmacologic-, cognitive-, behavioral- (lifestyle) or environmental-change methods." More recently, Gross (1998: 275) has described the regulation of emotions as involving "processes by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions." It is the nature of such emotion regulation coping responses that impacts the relationship between NA, tobacco use, and smoking relapse.

Contemporary functionalist theories of emotions emphasize their adaptive value (Gross 2002, 1998), viewing emotions as important sources of information regarding an individual's basic needs, concerns, and goals at any particular moment (Mennin et al. 2002). The construct of emotional intelligence (Mayer et al. 2001; Salovey, Woolery & Mayer 2001; Mayer & Salovey 1997) has provided an effective heuristic for understanding the impact of emotional processing on life adjustment and well-being. According to Salovey and colleagues (Mayer et al. 2001: 234), emotional intelligence consists of accuracy in "perceiving emotions, using emotions to facilitate thought, understanding emotions, and managing emotions in a way that enhances personal growth and social relations." According to Mayer, Salovey and Caruso (2000), the ability to appraise and identify emotions in oneself and others early in the processing of those emotions is fundamental to the construct of emotional intelligence. This aspect of emotional intelligence is consistent with the concept of antecedent reappraisal described below (Barlow, Allen & Choate 2004; Gross & John 2003) and may play a key role in mediating the relationship between NA and nicotine dependence.

Emotional Approach Coping

The active processing and expression of emotion is referred to as emotional approach coping (Stanton et al. 1994), in contrast to emotion suppression, and is hypothesized to be an adaptive form of affect regulation (Stanton et al. 2000). Emotional approach coping includes attempts to overcome or directly confront the source of distress (Stanton et al. 2000), whereas emotional avoidant coping includes efforts to reduce or avoid emotional distress. Emotional approach coping responses can be directed to the stressful situation itself or to the emotional distress generated by the situation. Approach coping includes various forms of emotional expression and other active forms of coping including problem solving (Holahan & Moos 1987). Both active processing and open expression of emotions have been shown to serve adaptive functions (Pennebaker, Mayne & Francis 1997). Writing about stressful experiences in an emotional way has been shown to have beneficial effects on emotional well-being (Pennebaker 1997). Expressive writing has been recently investigated as an adjunct to a brief office smoking cessation intervention (Ames et al. 2007). Although expressive writing appeared to facilitate smoking cessation, participants' low approval ratings for this intervention will need to be addressed in future studies of this treatment.

In the study of panic and other anxiety disorders, the concept of emotional approach or acceptance is emerging as an important theme in understanding the impact of interoceptive exposure and other emotional acceptance skills (Barlow, Allen & Choate 2004). This literature includes empirical studies showing the helpful effects of emotional acceptance coping and the detrimental impact of emotional avoidance coping among individuals who suffer from various anxiety disorders. For example, there is growing evidence that worry and rumination in the context of generalized anxiety disorder (GAD) represent forms of avoidance of aversive emotional experience (McLaughlin, Mennin & Farach 2007).

Implications for Addiction Treatment

The differentiation between helpful versus detrimental forms of emotion regulation coping has emerged in the substance use disorder treatment literature in studies investigating mediation of treatment outcomes. These studies show that higher levels of approach coping and lower levels of avoidance coping are associated with less use of alcohol and other drugs (Forys, McKellar & Moos 2007) and improved alcohol treatment outcomes (Levin, Ilgen & Moos 2007).

According to Moos (2007), substance abuse treatments that provide support through strong therapeutic alliances may facilitate greater awareness of internal experiences such as NA. Stronger treatment alliance has been shown to predict more acceptance-based coping and better quality of social relationships, which in turn were predictive of more successful substance use outcomes at two and five years following treatment (Gifford et al. 2006).

Originally thought to achieve their effect through extinction, exposure-based interventions that include internal emotional and physiological cues are now viewed as methods of facilitating emotional approach coping or emotional acceptance (Barlow, Allen & Choate 2004). Effective treatments for panic and other anxiety disorders involve exposure to interoceptive (emotional and physiological) sensations (Barlow 2002). Otto and colleagues (Otto, Powers & Fischman 2005; Otto, Safren & Pollack 2004) have developed an exposure-based intervention, Cognitive Behavior Therapy for Internal Cues (CBT-IC), that is designed to help break the links between stress, NA, craving, and drug use in a subgroup of individuals with substance use disorders who are characterized by affect avoidance motives for drug use. Preliminary evidence for the efficacy of this approach was obtained in a study involving opiate-dependent patients who had failed to respond to methadone treatment, counseling, and contingency management (Pollack et al. 2002). In addition, trauma-focused imaginal exposure has been shown to reduce alcohol cravings in patients with comorbid alcohol dependence and posttraumatic stress disorder (Coffey et al. 2006). Interoceptive exposure may help desensitize the smoker to the common relapse trigger of NA. Its helpfulness in the treatment of tobacco use has yet to be investigated.

ACCEPTANCE-BASED TREATMENTS AND SMOKING CESSATION

Twelve-Step programs have long recommended mindful and nonjudgmental observation of emotional distress (i.e., emotional acceptance), embedded in a highly structured spiritual and social context, as the primary strategy for approaching painful affect and difficult life circumstances (Moos 2007). Acceptance-based interventions that focus on mindfulness training have begun to appear in the substance use disorder treatment outcome literature (e.g., Marlatt et al. 2004; Marlatt 2002). However, to date, there is only preliminary empirical support for the efficacy of interventions aimed at facilitating emotional acceptance in smoking cessation (Davis et al. 2007; Vieten 2005; Gifford et al. 2004). Below, we briefly describe three forms of acceptance-based treatment that are designed to facilitate emotional acceptance, and discuss their potential role in facilitating smoking cessation.

Distress Tolerance

Brown and colleagues (2005) have investigated the concept of distress tolerance in relation to early smoking lapses. They defined distress tolerance as the ability to tolerate and persist on tasks in the presence of discomfort associated with NA and withdrawal symptoms. Brown and colleagues (2005) reviewed empirical studies that support the role of the regulation of and sensitivity to NA as important determinants of smoking lapses and relapse (Piasecki et al. 2003), and argued that the investigation of the ex-smoker's ability to tolerate the discomfort of nicotine withdrawal and associated NA may lead to innovative treatment strategies aimed at facilitating prevention of early relapse by strengthening distress tolerance. The treatment goal of increasing distress tolerance appears to be closely associated with emotional approach coping, emotional acceptance, and mindfulness. The assumptions underlying these coping responses and interventions challenge traditional concepts of affect regulation that focus on the need to control, regulate, and manage emotional distress. Interventions aimed at facilitating emotional acceptance need to be further developed and tested, particularly in subgroups of smokers with psychiatric comorbidities who are more prone to NA and lack adequate distress tolerance coping skills.

Interoceptive Exposure

Information-processing and conditioning models of relapse suggest that NA is tightly linked in memory with substance-related cognitions and scripts and that these processes frequently operate outside of a person's conscious awareness and are highly automated (Breslin, Zack & McMain 2002). Nicotine-dependent individuals become conditioned to smoke cigarettes in response to a variety of external and internal cues, including NA (Niaura et al. 1988). Through its emphasis on training and sharpening attention so that the ex-smoker becomes more conscious of previously automatic/habitual mental-emotional-behavioral patterns, interoceptive exposure can serve to increase former smokers' awareness of over-learned patterns of thought, behavior, and emotion, thereby helping to deautomate and disrupt the memory-based drug use (i.e., smoking) action plans that are frequently activated and enacted outside of conscious awareness (Breslin, Zack & McMain 2002; Tiffany 1990). The focus on cultivating an attitude of acceptance and curiosity (Baer 2002) while monitoring potential triggers such as NA may facilitate a deconditioning process for smokers (Breslin, Zack & McMain 2002; Blackledge & Hayes 2001).

Mindfulness

According to Bishop and colleagues (2004), mindfulness involves self-regulation of attention and a quality of relating to experience with curiosity, openness, and acceptance. This definition is based on self-regulation models of cognition and mood and on the metacognition model of psychopathology (Matthew 2004; Teasdale 1999a, b). Vieten (2005) is currently investigating the efficacy of mindfulness meditation for smoking relapse prevention. The results of this study are not yet available. Davis and colleagues (2007) investigated the efficacy of mindfulness-based stress reduction conducted in eight group sessions for smoking cessation in a single-group pilot study. They found that adherence to the meditation practice was associated with cessation of smoking and reductions in emotional distress.

Mindfulness is designed to facilitate emotional approach coping or emotional acceptance. When practiced in increasingly distressing moments, mindfulness functions like interoceptive exposure, encouraging individuals to attend repeatedly to NA cues while preventing maladaptive avoidant/impulsive responses (Baer 2002). This may serve to extinguish these responses, thereby effectively training a new conditioned response to NA (Breslin, Zack & McMain 2002; Linehan 1993). Studies have shown that smokers tend to rely on avoidant strategies to cope with stress, and that these maladaptive strategies predict future relapse (Kassel, Stroud & Paronis 2003; Wegner & Zanakos 1994). The orientation that a person cultivates in mindfulness represents a prototypic "approach-based" strategy. When faced with emotional distress, rather than using distraction or denial as a coping device, participants in mindfulness are instructed to simply be aware of whatever they find distressing. In the case of NA, they are taught to directly observe thoughts or feelings that emerge in their consciousness while not getting caught up in evaluation or carried away by behavioral reactivity.

In addition, mindfulness may promote self-efficacy for coping with relapse triggers. Self-efficacy for dealing with determinants of relapse without smoking is one of the strongest predictors of long-term quitting success (Shiffman et al. 2005; Shiffman et al. 2000; Prochaska & DiClemente 1992). In mindfulness, the repeated experience of observing rather than reacting to cravings/urges or emotional distress (Breslin, Zack & McMain 2002) may increase feelings of self-efficacy and sense of control as the person realizes that emotional states and impulses do not need to be avoided, denied, or acted upon. Studies in fact suggest that participation in mindfulness tends to enhance general feelings of self-efficacy and sense of control (Bishop 2002; Astin 1997). This may have particular relevance for the prevention of relapse from smoking, since self-efficacy has been identified as an important predictor of successful treatment outcomes and reduced likelihood of relapse.

Acceptance-Based Interventions and Metacognitive Change

Developing insight into the relationships between dysfunctional thought processes and mood states is considered to be a critical step in managing negative affective states effectively (Greenberger & Padesky 1996). Acceptancebased treatments complement standard cognitive-behavioral approaches to affect regulation in that their primary focus is not on changing faulty thinking patterns, but rather on noticing these patterns and altering the individual's relationship to the process of thinking itself (Teasdale 1999b). This metacognitive change allows the person to become more aware of thoughts and feelings and to relate to them from a wider, "de-centered" perspective. This metacognitive awareness involves training oneself to simply observe thoughts and feelings (whether interpreted or experienced as positive or negative) as transient mental events rather than as fixed aspects of the self or as necessarily accurate reflections of reality. Acceptance-based treatments may be particularly effective in preventing relapse in individuals with disorders of affect regulation, since skills in this type of metacognitive awareness can continue to be practiced and strengthened in the remitted (i.e., nondistressed) state (Teasdale et al. 2002; Teasdale 1999a). Although there is preliminary evidence supporting the efficacy of mindfulness and interoceptive exposure in the treatment of substance use disorders (e.g., Marlatt et al. 2004, Pollack et al. 2002), their application in smoking cessation remains to be determined in controlled clinical trials.

SUMMARY, CONCLUSIONS AND FUTURE DIRECTIONS

Higher levels of approach coping and lower levels of avoidance coping are associated with less use of alcohol and other drugs (Forys, McKellar & Moos 2007). Interventions aimed at cultivating emotional acceptance may facilitate prevention of relapse by enhancing recovering smokers' capacity to tolerate NA and increase awareness of unconscious conditioned responses. It may be that both tolerance of NA and conscious awareness of behavior, affect, and goals are important factors in preventing relapse. There is preliminary evidence (Davis et al. 2007; Gifford et al. 2004; Marlatt et al. 2004) to support the continued investigation of acceptance-based interventions in the treatment of chemical dependence.

Mindfulness and other acceptance-based approaches are based on the notion that there are many situations in which environments, thoughts, and emotions cannot be changed or controlled (Astin et al. 2001; Astin et al. 1999; Astin 1997). Evidence suggests that one of the characteristics that differentiates those who succeed at quitting smoking from those who do not succeed is that relapsers rely more on environmental change processes and social management of contingencies, whereas maintainers rely more on inner-directed, experiential processes focused on self-liberation (increasing inner capacity for exercising behavioral choice and control) (Prochaska & DiClemente 1992). Brown and colleagues (2005) argue that the way a person reacts to the discomfort of nicotine withdrawal may be a more promising avenue of investigation than severity of withdrawal and that the inability to tolerate the distress of nicotine withdrawal and associated NA is a key factor in early smoking lapse and subsequent relapse. It is our view that interventions that are directed specifically toward increasing tolerance of physiological, cognitive, and emotional distress will improve one's ability to regulate behavior in those situations where change is not possible, and may improve one's ability to cope in the traditional sense.

It has been proposed that the inability of cigarette smokers to tolerate the distress of nicotine withdrawal and associated NA is a key factor in early smoking lapse and subsequent relapse (Brown et al. 2005). Acceptance-based treatments may enhance smoking cessation and relapse prevention through: (a) cultivating approaching/accepting rather than avoiding/inhibiting NA; (b) reducing the conditioned response to smoke in response to distressing affect; (c) increasing self-efficacy to tolerate negative affect and other high risk situations; (d) heightening awareness of over-learned and largely unconscious cognitive-behavioral patterns; and (e) changing a person's relationship to thinking itself, enabling that person to continue to develop and practice this metacognitive skill during times of low distress or noncraving. Future studies are needed to test the effectiveness of acceptance-based treatment for smoking cessation and relapse prevention and to test the hypotheses proposed in this article regarding mechanisms by which positive outcomes are achieved.

Interventions aimed at facilitating distress tolerance or emotional acceptance need to be further developed and tested with smokers who are characterized by affect-avoidant motives. Trans-disciplinary theories and methods will continue to facilitate the understanding of the complex interactions among genetic, molecular, neuroregulatory, psychological, environmental, and social factors involved in the relationship between affect regulation and nicotine addiction. Future studies are needed that target affect regulation processes in addiction and tobacco use to develop more effective pharmacological and psychosocial treatments. For example, studies are needed to investigate the role of reappraisal and suppression of NA in the maintenance of tobacco use, cessation attempts, and relapse prevention. Mindfulness and other acceptance-based treatments appear to be promising approaches that need to be tested in controlled randomized trials. Finally, both laboratory studies and randomized controlled trials are needed to identify effective treatments and to increase our understanding of the mechanisms associated with successful outcomes.

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Timothy P. Carmody, Ph.D. *; Cassandra Vieten, Ph.D. ** & John A. Astin, Ph.D. ***

* Director, Health Psychology Program, San Francisco VA Medical Center; Clinical Professor, Department of Psychiatry, University of California, San Francisco.

** Associate Scientist, California Pacific Medical Center, San Francisco, CA.

*** Scientist, California Pacific Medical Center, San Francisco, CA.

Please address correspondence and reprint requests to Timothy P. Carmody, Ph.D., Director, Health Psychology Program, Mental Health Service (116B), VA Medical Center, 4150 Clement Street, San Francisco, CA 94121; Telephone: 415-221-4810 x2344; Telefax: 415-750-6987; Email: Timothy.Carmody@va.gov.
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Author:Carmody, Timothy P.; Vieten, Cassandra; Astin, John A.
Publication:Journal of Psychoactive Drugs
Article Type:Clinical report
Geographic Code:1USA
Date:Dec 1, 2007
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