تحمل پریشانی و فرسایش درمان پیش از استعمال دخانیات: بررسی روابط تعدیل کننده

This study focused on the understudied group of smokers who commit to a smoking research study and then subsequently drop out before completing even one session of treatment (pre-inclusion attrition). This is an important group typically not examined in their own right, leaving little knowledge about the characteristics that differentiate them from those who complete treatment. As an initial investigation, the current study examined affective risk factors for attrition in a sample of 53 adults (79% African-American; median income = $30,000–$39,999) enrolled in a smoking cessation study. Twenty-one (40%) participants never attended a session of treatment. Results indicated that lower psychological distress tolerance was related to pre-inclusion attrition, but only among women. Additionally, lower physical distress tolerance corresponded to pre-inclusion attrition, but only among men. These effects remained after including other important affective factors such as anxiety sensitivity and current depressive symptoms. No other predictors examined corresponded with pre-inclusion attrition in the present sample. Results indicate the need for more research attention to this at-risk group of smokers who do not continue on to cessation intervention.

Ample research has focused on identifying factors (e.g., depressive symptoms, withdrawal dynamics) related to relapse for those who receive smoking cessation treatment (e.g., Berlin and Covey, 2006 and Piasecki et al., 2002). However, studies typically pay less attention to individuals who engage in “pre-inclusion attrition” defined as completing an initial screening or intake assessment but then failing to participate in any aspect of the intervention (Howard et al., 1990 and Namenek Brouwer and Pomerleau, 2000). Of the limited research conducted on pre-inclusion attrition in smoking cessation, a handful of studies have considered individual difference factors that may limit initial treatment engagement. Factors that may be associated with pre-inclusion attrition include self-reported cessation motivation and quit intentions (Ahluwalia et al., 2002 and Schnoll et al., 2004), younger age and lower education (Ahluwalia et al., 2002 and Woods et al., 2002), weight concerns (Copeland, Marin, Geiselman, Rash & Kendzor, 2006), and history of psychotropic medication use (Curtin, Brown & Sales, 2000). Moving beyond these variables, affective vulnerabilities (e.g., depressive symptoms) have been shown to relate to poorer treatment outcome in smokers (e.g., Kassel & Hankin, 2006), and may also be useful for consideration specific to pre-inclusion attrition. Despite the extensive body of literature linking depression status or symptoms to poor cessation outcomes, these affective vulnerabilities have been unrelated to pre-inclusion attrition (El-Khorazaty et al., 2007), as well as indices of readiness to change smoking behavior and smoking treatment acceptance (Haug et al., 2005 and Prochaska et al., 2004). Some evidence suggests that anxiety sensitivity (AS), a dispositional trait-like characteristic reflecting the fear of anxiety-related experiences, is related to factors associated with pre-treatment attrition including motivation to quit smoking (Zvolensky et al., 2004 and Zvolensky et al., 2007), barriers to quitting smoking (Zvolensky et al., 2006) and early smoking lapse (e.g., Brown, Kahler, Zvolensky, Lejuez & Ramsey, 2001). However, a direct link from anxiety sensitivity to pre-treatment attrition has yet to be established. There may also be other relevant vulnerabilities that have yet to be examined in relation to pre-inclusion attrition including distress tolerance which is defined as an individual's behavioral persistence towards a goal in the presence of affective and/or physical distress (Daughters et al., 2005a and Brown et al., 2005). Low distress tolerance has been associated with greater substance use (Quinn, Brandon & Copeland, 1996), shorter length of smoking cessation and drug use abstinence (Brandon et al., 2003, Brown et al., 2002 and Daughters et al., 2005a), and early substance use treatment drop out (Daughters et al., 2005b). A limitation of this literature is that studies were retrospective (Daughters et al., 2005a and Brown et al., 2002) or limited to participants who completed treatment or engaged in some treatment but failed to achieve abstinence (Brandon et al., 2003 and Daughters et al., 2005b). Thus, the current literature does not highlight the potential role of distress tolerance in relation to pre-inclusion attrition in a smoking intervention. In considering the link between distress tolerance and pre-inclusion attrition, it may be useful to conceptualize distress tolerance within the framework of negative reinforcement (Brown et al., 2005 and Daughters et al., in preparation), in which distress tolerance is considered an assessment of behavioral avoidance of or escape from affective or physical distress. This framework draws upon Baker, Piper, McCarthy, Majeskie and Fiore (2004) negative reinforcement model of addiction in which initially escape and ultimately avoidance of affective distress are considered the prepotent motive of addictive behavior maintenance, and is consistent with other negative reinforcement conceptualizations of smoking motivation (Eissenberg, 2004). Additionally, avoidance behavior is commonly implicated in both a lack of treatment-seeking for health problems (e.g., Moore et al., 2004) and treatment non-adherence (e.g., Waldroup, Gifford, & Kalra, 2006). Thus it is likely that those individuals who have the lowest levels of distress tolerance will also be most likely to exhibit pre-inclusion attrition from a smoking cessation intervention. Specifically, distress tolerance tasks provide an analog assessment of avoidance/escape behavior that is relevant to the behavior exhibited in not following through with treatment after an initial effort is made to attend a baseline session. 1.1. Current study The aim of the current study was to examine the role of psychological and physical distress tolerance as predictors of pre-inclusion attrition among a sample of adults who met entry criteria and completed a baseline assessment for a randomized control trial of a piloted behavioral activation cessation intervention for smokers with elevated depressive symptoms. Given poor cessation outcomes associated with depression-related vulnerabilities (e.g., Berlin & Covey, 2006), but also the lack of findings connecting depressive symptoms to pre-inclusion attrition (El-Khorazaty et al., 2007), it is important to investigate other possible mechanisms contributing to pre-inclusion attrition in this at-risk group. We also examined the role of gender as a moderator of the relationship between distress tolerance and pre-inclusion attrition given women's smoking behavior may be more directly driven by motivation to cope with negative affect and stress (e.g., al'Absi, 2006 and Colamussi et al., 2007) while men's smoking may be more driven by physiological or pharmacological effects of nicotine (Perkins, 2001 and Perkins et al., 2006). Thus, it was expected that physical distress tolerance would have a stronger relationship with pre-inclusion attrition for men while psychological distress tolerance would have a stronger relationship with this outcome for women.

Despite limitations including a small sample characterized by elevated depressive symptoms and a limited number of covariates, this is the first study to examine the relationship between psychological and physical distress tolerance and pre-inclusion attrition from a smoking cessation intervention. Thus a challenge is developing effective strategies for targeting and recruiting both men and women who may be particularly likely to engage in treatment avoidance behavior and subsequently unlikely to continue with a cessation program. It would also be useful to further explore the gender differences here both as they relate to pre-inclusion attrition but also to the extent that they shed light on cessation outcomes, with somewhat different targets possibly emerging across gender (i.e., psychological distress tolerance for women, physical distress tolerance for men). Combined with the uniqueness of our sample in the high representation of low income minority smokers who are typically underrepresented in smoking cessation research (El-Khorazaty et al., 2007) and at risk for poor cessation outcomes (Moolchan et al., 2007), the current study suggests how the construct of distress tolerance may be helpful to marshal support needed to help individuals commit to treatment while noting the importance of considering the role of demographic variables in this relationship.