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Published in final edited form as: Addict Behav. 2019 Jul 10;99:106048. doi: 10.1016/j.addbeh.2019.106048

Distress Intolerance and Withdrawal Severity among Daily Smokers: The Role of Smoking Abstinence Expectancies

Rachel L Rosen a, Allison M Borges a, Mindy M Kibbey a, Marc L Steinberg b, Teresa M Leyro a, Samantha G Farris a,*
PMCID: PMC6791772  NIHMSID: NIHMS1537521  PMID: 31421585

Abstract

Background:

Distress intolerance (DI), the perceived inability to withstand distress, is implicated in cigarette smoking maintenance. Greater DI may contribute to anticipation of negative outcomes from smoking abstinence, which in turn could contribute to withdrawal symptom severity. The current study aimed to evaluate (1) the association between DI and acute abstinence expectancies and (2) the potential mediating role of abstinence expectancies in the relationship between DI and withdrawal symptom severity.

Method:

Participants (n = 444) were daily smokers who reported at least one prior quit attempt, participating in a larger online study on distress and smoking. DI, subjective nicotine withdrawal, and smoking abstinence expectancies were assessed using the Distress Tolerance Scale (DTS), Minnesota Nicotine Withdrawal Scale (MNWS), and Smoking Abstinence Expectancies Questionnaire (SAEQ).

Results:

DTS was significantly negatively associated with SAEQ, specifically Negative Mood (r = −.37, p < .001), Somatic Symptoms (r = −.47, p < .001), and Harmful Consequences (r = −.59, p <.001) subscales, but was not associated with Positive Expectancies subscale (r = .05, p = .31). Results indicated a significant effect of DTS on withdrawal symptom severity via SAEQ. Follow-up analyses indicated that the indirect effects were driven specifically by SAEQ Negative Mood and Harmful Consequences subscales.

Discussion:

DI is related to more negative abstinence expectancies, particularly affective aspects of abstinence, which may contribute to the severity of nicotine withdrawal symptoms. This study provides initial evidence of a specific cognitive process that may explain why DI contributes to heightened subjective experience of nicotine withdrawal symptoms.

Keywords: distress intolerance, nicotine withdrawal, abstinence, expectancy, cognitive vulnerability

1. Introduction

Distress intolerance (DI) is conceptualized as one’s perceived or actual inability to withstand distress caused by emotional, mental, or physical discomfort (Leyro, Bernstein, Vujanovic, McLeish, & Zvolensky, 2011; Simons & Gaher, 2005). DI is a core psychological vulnerability factor implicated in the maintenance of cigarette smoking (Leventhal & Zvolensky, 2015; Veilleux, 2019), including poorer smoking cessation outcomes. Smokers with elevated DI have greater difficulties quitting smoking, which has been documented retrospectively (Brown, Lejuez, Kahler, & Strong, 2002) and prospectively in terms of risk for smoking lapse (Abrantes et al., 2008; Brown et al., 2009) and relapse (Kahler, McHugh, Metrik, Spillane, & Rohsenow, 2013; Rohsenow et al., 2015). DI also appears to increase during periods of acute smoking deprivation compared to usual smoking (Bernstein, Trafton, Ilgen, & Zvolensky, 2008), which may in part be due to aversive abstinence-induced withdrawal states. Indeed, laboratory data indicate that DI can amplify the experience of and reaction to aversive internal sensations in the context of acute abstinence-induced distress (Abrams et al., 2011; Marshall et al., 2008; Zvolensky et al., 2005), which in turn can enhance the subjective experience of nicotine withdrawal and craving (Farris, Zvolensky, Otto, & Leyro, 2015; Mathew et al., 2018; Volz et al., 2014). Heightened reactivity to nicotine withdrawal symptoms may also explain why smokers with higher DI (compared to lower) demonstrate greater nicotine consumption following overnight abstinence (Perkins, Karelitz, Giedgowd, Conklin, & Sayette, 2010).

The aforementioned findings are consistent with the recognition that one’s subjective experience of nicotine withdrawal symptoms may be a stronger predictor of smoking cessation outcomes than objective indices of withdrawal severity (e.g., Brown et al., 2005; Piasecki, 2006). An individual’s expectancies, or beliefs, about the experience of acute smoking abstinence (i.e., smoking abstinence expectancy), may comprise an a priori cognitive process that contributes to heightened experience of withdrawal symptoms. For example, negative smoking abstinence expectancies, or beliefs about the expected negative effects of abstinence, are associated with more severe negative affect and craving during acute abstinence, whereas positive abstinence expectancies, or more optimistic beliefs about the expected effects of nicotine withdrawal, are associated with less severe withdrawal symptoms (Hendricks & Leventhal, 2013). Moreover, specific aspects of negative smoking abstinence expectancies, like beliefs about the effect of abstinence on negative mood (e.g., “I would feel grouchy”), somatic symptoms (e.g., “I would feel short of breath”), or harmful outcomes (e.g., “I would feel like I’m dying”), have been linked to the subjective severity of nicotine withdrawal (Abrams, Zvolensky, Dorman, Gonzalez, & Mayer, 2011).

Although not yet examined, smokers’ perceived ability to withstand distress (or inability, characterized by DI) may contribute to the formation of negative expectancies about the smoking cessation process, including smoking abstinence, which in turn could account for elevated severity of withdrawal symptoms. Prior evidence indicates that DI is related to other cognitive biases, including expectancies that smoking will alleviate negative affect (Leyro, Zvolensky, Vujanovic, & Bernstein, 2008; Shadur, Ninnemann, Lim, Lejuez, & MacPherson, 2017). Given that smokers with elevated DI tend to rely on cigarettes for managing distress states, these smokers may also hold negative beliefs about the experience of smoking abstinence (e.g., as seen in other cognitive vulnerabilities; Farris, Langdon, Dibello, & Zvolensky, 2015).

The current study was designed to evaluate the relationship between DI, acute smoking abstinence expectancies, and subjective severity of nicotine withdrawal symptoms. Specifically, we evaluated the direct and indirect associations between perceived DI and withdrawal severity during a prior smoking cessation attempt, via acute smoking abstinence expectancies in a sample of daily cigarette smokers who made a least one prior lifetime quit attempt. We hypothesized that DI would be associated with greater negative expectancies about acute smoking abstinence, which in turn would be associated with more severe nicotine withdrawal symptoms during a prior quit attempt. To increase specificity of these findings, a secondary aim of this study was to explore the indirect effects of different types of smoking abstinence expectancies, including expectancies about harmful consequences, somatic symptoms, or negative mood.

2. Method

2.1. Participants

Participants (N = 550) were adult daily smokers from the United States who participated in a larger online study on distress and smoking (Farris, DiBello, & Zvolensky, 2018). The parent study included participants on the basis of the following criteria: ≥ 18 years old, daily smoker for ≥ one year, smoking ≥ 5 cigarettes per day, and cigarettes were the primary tobacco product used. Exclusion criteria included ≥ 50% reduction in cigarettes per day in the past month. The current study involved secondary analyses of a subset of participants who reported at least one lifetime smoking quit attempt (n = 444; Mage=44.7 years, SD = 13.1, 54.1% female).

2.2. Procedure

Interested and eligible individuals were recruited through Qualtrics Panels. Individuals were provided information about the anonymous and voluntary nature of the study and were given the option to “agree” or “disagree” to participate. Individuals who agreed to participate were routed to the online survey that lasted approximately forty minutes, followed by an experimental, computerized persistence task. Data were retained for analyses if all validity ‘check’ questions were correctly answered. Participants received Qualtrics credits for participation in the study, which could be used to purchase items on the Qualtrics Panels portal. The current study is a secondary analysis of data collected prior to the experimental manipulation. The full study protocol is described elsewhere (Farris, Dibello, & Zvolensky, 2018). All study procedures were approved by the institutional review board where the study took place.

2.3. Measures

A demographics questionnaire was used to collect basic demographic information including biological sex, race, ethnicity, education and income.

Patient Health Questionnaire (PHQ; Spitzer, Kroenke, & Williams, 1999) is a self-report questionnaire that assesses psychological functioning. In the current study, we used specific subscales from the PHQ used to evaluate symptoms of depression, generalized anxiety, and alcohol use. Higher scores indicate higher levels of symptomatology.

Smoking History Questionnaire (SHQ; Brown et al., 2002) is a self-report questionnaire used to assess smoking characteristics, including initiation of smoking and quitting behavior. Participants were asked to report the date of their most recent quit attempt, which was used to derive recency of quit attempt (in years).

Fagerström Test for Cigarette Dependence (FTCD; Fagerström, 2012; Heatherton, Kozlowski, Frecker, & Fagerström, 1991) is a widely used self-report questionnaire that assesses cigarette dependence. Possible scores range from 0 to 10, with higher scores indicating greater cigarette dependence.

Distress Tolerance Scale (DTS; Simons & Gaher, 2005) is a 14-item self-report questionnaire used to assess tolerance for emotional distress. Items are rated on a 5-point Likert-type scale ranging from 1 (Strongly agree) to 5 (Strongly disagree). A total score is derived by calculating a mean score across four subscales. The DTS is validated in daily cigarettes smokers (Leyro et al., 2011). Lower DTS scores are indicative of higher DI.

Smoking Abstinence Expectancies Questionnaire (SAEQ; Abrams et al., 2011) is a 28-item self-report questionnaire used to assess participants’ perceived likelihood of experiencing positive and negative consequences of acute smoking abstinence. Items are rated on a Likert-type scale ranging from 0 (very unlikely) to 6 (very likely). Four subscales (Somatic Symptoms, Negative Mood, Harmful Consequences, and Positive Consequences) are scored by summing select items. The Positive Consequences subscale is reverse coded, and a total score is calculated by summing the four subscale scores.

Minnesota Nicotine Withdrawal Scale (MNWS; Hughes & Hatsukami, 1986) is a 9-item self-report questionnaire that assesses the severity of nicotine withdrawal symptoms. For the current study, participants were asked to respond based on their experiences during their most recent quit attempt. Items are rated on a Likert-type scale ranging from 0 (none) to 4 (severe), and a total score is calculated by summing all responses.

2.4. Data Analysis

Five cases had instances of missing item-level data on the MNWS; these values were imputed using mean-replacement from the mean of the available data for that case. Missingness was also detected on two items from the SHQ used to describe prior quit history, presence of ever making a quit attempt lasting >24 hours (n = 3 missing) and recency of most recent quit attempt (n = 8); these instances of missingness were addressed using listwise deletion for these descriptive analyses. All other cases had complete data on study measures. Next, descriptive statistics were used to describe the sample characteristics at baseline. The primary analyses were conducted using PROCESS (v2.05; Hayes, 2013) to test for direct and indirect effects of distress tolerance (DTS total score) on withdrawal symptom severity (MNWS total score) via smoking abstinence expectancies (SAEQ) total score and four smoking abstinence expectancies subscales (negative mood, harmful consequences, somatic symptoms, and positive consequences). Theoretically relevant variables were considered for inclusion as model covariates: cigarette dependence (FTND), sex, anxiety symptoms, depression symptoms, and recency of last quit attempt. We obtained 95-percentile confidence intervals (CIs) for regression estimates and used bootstrapping with 10,000 resamples.

3. Results

3.1. Sample Characteristics

Participants (N = 444) were primarily female (n = 240; 54.1%), white (n = 401; 90.3%), and non-Hispanic or Latino (n = 414; 93.2%). Approximately half of the sample was married (n = 242; 54.5%) and were employed full-time (n = 225; 50.7%), and the majority completed at least some undergraduate education (n = 310; 69.8%). Participants reported smoking an average of 17.3 cigarettes per day (SD = 8.4) and had moderate levels of cigarette dependence as measured by the FTCD (M = 5.6; SD = 1.9). On average, smokers reported 3.4 past quit attempts (SD = 5.5), with the majority of the sample (90.9%) reporting at least one quit attempt that lasted at least 24 hours. On average, participants reported that their most recent quit attempt occurred 5.4 years ago (SD = 7.7; range = 0 to 45 years).

3.2. Bivariate Correlations

Means, standard deviations, and bivariate correlations between study variables are summarized in Table 1. DTS was negatively correlated with withdrawal symptom severity, which was a small-medium sized association. Lower DTS scores (reflecting higher DI) were associated with the higher scores on the SAEQ, reflecting stronger expectancies about the effects of acute smoking abstinence on Negative Mood, Somatic Symptoms, and Harmful Consequences subscales. However, the DTS was not significantly associated with SAEQ Positive Consequences subscale. In addition, the SAEQ Total score and negative expectancies (Negative Mood, Harmful Consequences, and SAEQ Somatic Symptoms) demonstrated medium to large positive associations with withdrawal symptom severity, whereas the SAEQ Positive expectancies subscale demonstrated a small association with withdrawal severity. Recency of last quit attempt was not significantly correlated with withdrawal symptom severity and was not retained as a model covariate.

Table 1.

Means, standard deviations, and bivariate correlations (n = 444).

Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.a
1. Sex - .01 .09 .03 −.04 .07 .21** −.17** −.04 .20** .10* .05
2. Depression severity - .84** .27** −.56** .54** .40** .49** .58** −.06 .52** −.17**
3. Anxiety severity - .28** −.55** .56** .48** .43** .56** .03 .58** −.18**
4. Cigarette dependence - −.23** .34** .34** .23** .29** .05 .36** −.07
5. Distress intolerance - −.52** −.37** −.47** −.59** .05 −.45** .12*
6. SAEQ Total - .83** .74** .87** .23** .65** −.08
7. SAEQ Negative - .46** .60** .17** .64** −.02
8. SAEQ Somatic - .82** −.34** .40** −.16**
9. SAEQ Harmful - −.16** .56** −.14**
10. SAEQ Positive - .14** .12*
11. Withdrawal severity - −.05
12. Recency of last quit attempt -
Mean or n 240 7.50 5.11 5.58 3.20 77.00 23.77 12.68 12.81 27.74 18.13 5.35
SD or % 54.1% 7.13 3.96 1.87 1.01 28.46 10.14 10.68 11.32 10.17 9.87 7.72
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Note:

*

p<.05,

**

p<.01;

a

Sample size is n = 436; Sex (0=Male; 1=Female); Depression severity = Patient Health Questionnaire-9; Anxiety severity = Generalized Anxiety Disorder-7; Cigarette Dependence = Fagerström Test for Cigarette Dependence; Distress intolerance = Distress Tolerance Scale (Total Score); SAEQ = Smoking Abstinence Expectancies Questionnaire – Total Score, Negative Mood, Somatic Symptoms, Harmful Consequences, and Positive Consequences; Withdrawal Severity = Minnesota Nicotine Withdrawal Scale. Recency of last quit attempt = Smoking History Questionnaire (in years). Variables numbered 1–12 correspond with numbered columns.

3.3. Tests of Direct and Indirect Effects

Regression results are presented in Figure 1. The total effect model was significant (R2 = 0.40, df = 5, 438, F = 58.99, p < .0001; path c), as was the full model with smoking abstinence expectancies (R2 = 0.51, df = 6, 437, F = 75.78, p < .0001). The direct effect (path c’) of DTS on withdrawal symptom severity after controlling for abstinence expectancies was non-significant. Regarding the indirect effect, lower DTS scores (reflecting greater intolerance) were associated with more severe self-reported withdrawal symptoms during the recent quit attempt indirectly through acute smoking abstinence expectancies (a*b=−1.15, CI95%=−1.70 – (−0.70)). When the predictor (X) and mediator (M) variables were reversed in the model, the indirect effect was non-significant (b = 0.004, SE = 0.005, CI95% = −0.004 – 0.014).

Figure 1.

Figure 1.

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Indirect effect of smoking abstinence expectancies.

Note: ***p<.001. a*b= indirect effect. Path c (path c’) are presented for the associations between DTS and MNWS.

3.4. Test of Specific Indirect effect of SAEQ Subscales

Follow-up analyses were conducted to test the association between DTS and withdrawal symptom severity via specific facets of smoking abstinence expectancies (see Figure 2). The full model including the four SAEQ subscales was significant (R2 = 0.55, df = 9, 434, F = 57.95, p < .0001). The direct effect (path c’) of DTS in terms of withdrawal symptom severity, after controlling for abstinence expectancies, was non-significant. Regarding the indirect effects, the effects of SAEQ Negative Mood (a*b=−0.52, CI95%=−1.01 – (−0.12)) and Harmful Consequences (a*b=−0.70, CI95%=−1.29 – (−0.21)) subscales were significant. The indirect effects of SAEQ Somatic Symptoms and SAEQ Positive Consequences subscales were non-significant.

Figure 2.

Figure 2.

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Specific indirect effect of SAEQ subscales.

Note: *p<.05, **p<.01, ***p<.001. a*b= indirect effect. The paths c/paths c’ for DTS on MNWS are not presented in the figure above. DTS was associated with MNWS: path c (b=−1.58, t=−3.55, p<.001); path c’ (b=−0.63, t=−1.51, p=.13).

4. Discussion

The findings provide novel evidence for smoking abstinence expectancies as a potential explanatory process linking DI and withdrawal symptom severity. Specifically, findings indicated that DI was related to greater negative expectancies about acute smoking abstinence, which, in turn, was associated with more severe nicotine withdrawal symptoms experienced during a prior quit attempt. The current findings build upon prior research linking DI with expectancies about the effects of cigarette smoking, specifically those related to affect modulation (Leyro et al., 2008; Shadur et al., 2017) and subjective experience of withdrawal severity (Farris et al., 2015; Mathew et al., 2018), and extend this line of work by highlighting a specific explanatory pathway (i.e., negative smoking abstinence expectancies) through which DI may influence perception of withdrawal symptoms.

DI appears to be related to various aspects of negative smoking abstinence expectancies – including concerns about how smoking abstinence will influence mood, result in somatic symptoms, and potentially cause harm. Moreover, findings provide unique evidence that DI may be linked to withdrawal severity due to specific concerns about abstinence’s effect on negative mood and harmful consequences. Given that smokers with elevated DI demonstrate heightened reactivity to stress (Farris et al., 2015), these individuals may be prone to the formulation of biased expectancies about situations or events that may be threatening or uncomfortable, like being abstinent from smoking. These may occur through anticipated changes in mood, such as feeling frustrated or short tempered, or being fearful of the consequences of abstinence-induced distress (e.g., concerned about being embarrassed or having a panic attack). Over time, persistent smoking may serve to not only reinforce automatic negative expectancies about abstinence, but also may create a prominent attentional bias toward affective symptoms of withdrawal experienced during quit attempts. Indeed, smokers report acute increases in negative affect and cigarette cravings when primed with contextual cues related to nicotine withdrawal (Farris et al., 2018).

It is also noteworthy that the affective consequences of smoking abstinence (e.g., feared emotions or psychological states), rather than somatic symptoms, were uniquely implicated in the link between DI and withdrawal severity. This patterning of findings is likely driven by domain-similarity between the SAEQ affective subscales and the DTS, which taps one’s perceived (in)ability to withstand emotional or psychological distress (Simons & Gaher, 2005). Although not tested here, it is possible that other domains captured by the DI construct, like intolerance of physical discomfort (Schmidt, Richey, & Fitzpatrick, 2006) or smoking-specific distress (e.g., smoking abstinence; Sirota et al., 2010) may be more strongly related to somatic concerns about smoking abstinence, and explain the link to withdrawal severity. It is also possible that the lack of indirect effect for the SAEQ somatic symptoms subscale is driven by measurement variance. The DTS and SAEQ somatic symptom subscale were correlated at the bivariate level, but SAEQ somatic symptoms did not indirectly explain the link between the DTS and withdrawal severity. The somatic symptoms queried by the SAEQ somatic subscale reflect panic hyperarousal (e.g., “I would feel short of breath”, “My feet would feel tingly”), which are distinct from somatic symptoms associated with nicotine withdrawal assessed by the MNWS (e.g., “Nausea”, “Constipation”).

To our knowledge, this is the first study to (a) examine the relationship between DI and smoking abstinence expectancies, and (b) provide initial evidence of a potential mechanistic pathway through which DI, specifically one’s perceived intolerance to psychological or emotional distress, may influence the subjective experience of nicotine withdrawal symptoms (i.e., via smoking abstinence expectancies). These findings provide increased specificity to existing theoretical frameworks linking DI and the persistence of smoking (Brown et al., 2005; Leventhal & Zvolensky, 2015; Veilleux, 2019).

The findings from the current study should be interpreted in light of several limitations. First, the sample was comprised of primarily white, non-Hispanic smokers, which limits generalizability to more racially and ethnically diverse groups of smokers. Second, withdrawal symptoms were rated in reference to one’s “most recent quit attempt,” which ranged in recency from <1 to 45 years and the duration of the quit attempt was not systematically assessed. These factors could contribute to variability in salience of withdrawal experience, although recency in quit attempt was not significantly related to recalled withdrawal severity. Additionally, severity of nicotine withdrawal can be influenced by the use of pharmacological cessation treatment, like nicotine replacement therapies, which are designed to attenuate withdrawal; however, the current investigation did not assess the use of pharmacotherapy during the most recent quit attempt. Thus, this additional source of measurement bias should be considered. Third, use of illicit substances, including cannabis, was not assessed in the original study, and as such, we are unable to evaluate the effects of other non-tobacco substance use behavior on the associations presented. Fourth, data were cross-sectional in nature, which limits the ability to determine the temporal relationship among DI, expectancies about smoking abstinence and withdrawal symptom severity. Future studies should assess the causal nature of the relationship between DI, abstinence expectancies, and withdrawal symptom severity. Last, this study relied entirely on self-report assessments that were administered online. Online data collection could introduce measurement bias (e.g., due to low effort, environmental distractions). As is standard with online data collection, we utilized quality-control procedures (i.e., attentional check questions) to help attenuate biases. Future work is needed to understand how behavioral aspects of DI (i.e., one’s actual inability to withstand distress, rather than perceived ability) may differentially relate to smoking abstinence expectancies and subsequent withdrawal experiences.

Overall, the current study highlights the role of DI in contributing to negative expectancies about the affective experience of withdrawal during acute smoking abstinence. Additionally, findings underscore the potential explanatory role of negative abstinence expectancies in the process of quitting smoking. Future work is needed to provide greater specificity to this patterning of effects. For example, although not studied here, DI is influenced by state-level contextual factors (Veilleux, 2019). For instance, smokers demonstrate acute increases in DI to respiratory distress in the context of acute smoking deprivation compared to smoking as usual (Bernstein et al., 2008). Thus, future laboratory-based studies that experimentally manipulate nicotine abstinence could provide more nuanced information about how smoking abstinence acutely influences DI and in turn, momentary expectancies about abstinence, and their subsequent effect on smoking behavior. Additionally, understanding the nature of DI, abstinence expectancies and withdrawal experiences in different types of tobacco and nicotine using populations (e.g., intermittent smokers, electronic-cigarette users) may advance our knowledge of cognitive and affective processes that contribute to persistent use of these products. Finally, these findings could inform the refinement of existing DI-based smoking cessation interventions (e.g., Brown et al., 2018). For example, it may be useful to specifically assess expectancies about acute smoking abstinence and address biases, such as the belief that abstinence may be intolerable, that may otherwise contribute to poor cessation outcomes.

Highlights.

  • DI is associated with more severe nicotine withdrawal symptoms

  • DI is associated with greater negative expectancies about acute smoking abstinence

  • Smoking abstinence expectancies indirectly predict the DI-withdrawal link

Role of Funding Sources:

Funding for this research was provided by a Qualtrics Behavioral Research Grant to the last author. This work was also funded by a pre-doctoral National Research Service Award from the National Institute of Drug Abuse (F31-DA043934) awarded to AMB. Qualtrics nor NIDA had no role in the study design, collection, analysis or interpretation of data, writing the manuscript, or the decision to submit the paper for publication.

Footnotes

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Conflict of Interest: MLS has consulted for Pfizer, Inc. No other authors have conflicts to disclose.

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