A novel stress-based intervention reduces cigarette use in non-treatment seeking smokers

Abstract

Tobacco use is the leading cause of preventable mortality worldwide. Since current smoking cessation aids show only modest efficacy, new interventions are needed. Given the evidence that stress is a potent trigger for smoking, the present randomized clinical trial tested whether stress could augment the effects of a memory updating (retrieval-extinction) intervention. Non-treatment seeking smokers (n = 76) were assigned to one of four conditions composed of either a stressful or non-stressful psychosocial challenge followed by either smoking or neutral cues. Ten minutes after this manipulation, all underwent a 60-minute extinction procedure during which they viewed smoking-related videos and images and manipulated smoking paraphernalia. Compared to participants who were not exposed to the laboratory stressor, the stressor-exposed groups exhibited greater psychophysiological responses during their intervention and greater decreases in cigarette use at two- and six-weeks follow-up independent of smoking cue exposure. Together, these findings suggest that the ability of stress to activate cigarette seeking processes can be exploited to decrease cigarette use. With replication, the stress-based intervention could become a novel strategy for decreasing cigarette use in non-treatment seeking smokers.Clinicaltrials.gov identifier: NCT04843969.

Fig. 1. Experimental design and timeline.

During the initial assessment and test sessions 1, 2 and 3, a novel smoking-related video was shown to participants. Physiological measures (heart rate (HR) and skin conductance (SC)) were collected prior to and during the last minute of each video presentation. During these same visits, blood pressure (BP) and self-reported cigarette craving and urge to smoke scores were collected pre- and post-video. On the day of the behavioral intervention, baseline physiological measures (HR, SC, and BP) and self-report data were gathered, followed by one of four conditions (phase 1): stress task and smoking cue, stress task and neutral cue, non-stressful task and smoking cue, or non-stressful task and neutral cue. Physiological and craving measures were collected and followed by a 10-minute break. All participants then went through the extinction protocol (phase 2) consisting of additional smoking videos, smoking images, and the manipulation of smoking-related paraphernalia. Immediately after phase 2, physiological and craving measures were gathered again.

Fig. 2. CONSORT Flow Diagram.

Reasons for withdrawal after randomization included reduction or cessation in cigarette use prior to the intervention, misreporting cigarette use, and a participant having dyscalculia. Scheduling conflicts or time constraints were the primary reasons why some participants declined to participate.

Fig. 3. The stress task-induced psychophysiological and craving responses during the behavioral intervention.

During phase 1 (A), participants exposed to the stress task exhibited larger increases in physiological (SC and systolic BP) and craving measures (QSU-Brief and TCQ-SF scores). During phase 2 (B), physiological measures did not significantly differ between groups, but participants previously exposed to the control task exhibited greater smoking cue-induced craving responses (QSU-Brief). BP: blood pressure; SC: skin conductance; TCQ-SF: Tobacco Craving Questionnaire – Short Form; QSU-Brief: Questionnaire on Smoking Urges – Brief. EMM: estimated marginal mean; SEM standard error of the mean. *P < 0.05, ***P < 0.001.

Fig. 4. The stress-based memory intervention led to decreased cigarette use at follow-up.

A Participants in the stress-based intervention significantly decreased their average daily cigarette use from baseline to the tests 2 and 3 (two and six weeks after the intervention, respectively). B Cigarette use in the stress group participants decreased by 14% at two weeks (test 2) and by 26% at six weeks (test 3), while the control group showed decreases of 9% and 10%, respectively. EMM: estimated marginal mean; SEM: standard error of the mean. In the stress group: ***P ≤ 0.001 compared to baseline, #P < 0.05 compared to test 2.