A Cognitive Behavioral Stress Intervention for Women Who Smoke

Objectives Aim 1: Examine the effect of using cognitive reappraisal and HRVb in a single session on stress task performance. Investigators expect that participants assigned to practice both cognitive reappraisal and HRVb will demonstrate greater cognitive performance and persistence on stressful tasks during a laboratory visit in contrast to a control group of female smokers.

Aim 2: Examine the effect of using cognitive reappraisal and HRVb on short-term HRV, craving, and affect. Investigators expect that participants assigned to practice both cognitive reappraisal and HRVb will exhibit the greatest HRV adaptations, and demonstrate less reactive craving and affect by the end of the visit than participants randomized to a control group.

III. Background and Rationale Twenty percent of all deaths in the United States, or more than 480,000 deaths each year, are attributable to smoking (USDHHS, 2014). Cigarette smoking remains the leading preventable cause of death, with 16.8% of adults currently smoking (CDC, 2015) and over 16 million Americans living with a smoking-related disease (USDHHS, 2014). Smoking remains difficult to quit; even with the best available current treatments, quit attempts are successful 35% of the time or less (Garrison & Dugan, 2009). Smoking cessation and relapse to smoking is by far the most frequent path of cigarette use for smokers (Garcia-Rodriguez et al., 2013; Piasecki, 2006; Rafful et al., 2013). Stress has been implicated as a primary mechanism in smoking relapse (McKee et al., 2003; Baer et al., 1989; Cohen & Lichtenstein, 1990), often triggering increases in negative affect (Shiffman, 2005; Shiffman & Waters, 2004) and exposing difficulties in emotion regulation (Farris, Zvolensky, & Schmidt, 2015). Evidence suggests that stress prospectively predicts smoking lapse (Shiffman & Waters, 2004) and lapses triggered by stress progress more quickly to relapse (Shiffman et al., 1996), suggesting deficits in the ability to cope with stress.

In particular, women's smoking habits show trends that are different from men's: reports have shown that women consume more cigarettes than men (Hammond, 2009; Ng et al., 2014) and are less likely to successfully quit smoking than men (Cepeda-Benito et al., 2004; Perkins, 2001; Piper et al., 2010). While stress has been implicated in relapse for all smokers, recent evidence indicates that stress is a principal factor in promoting relapse to smoking in females, in part because women appear to be more strongly predisposed to stress responses (Torres & O'Dell, 2016). It is therefore likely that women are at particular risk for relapse due to stress.

Cognitive reappraisal has demonstrated positive effects on stress responding and smoking-related outcomes. Cognitive reappraisal is the reframing of a situation in order to influence one's emotional response to it (Gross, 1998). Compared with acceptance and suppression, reappraisal as measured by the Emotion Regulation Questionnaire (ERQ; Gross & John, 2003) is associated with overall lower craving and negative affect during craving inductions and stress tasks, as well as improved performance on a cognitive stress task (Szasz, Szentagotai, & Hofmann, 2012). Fucito, Juliano, and Toll (2010) found that frequent reappraisal on the ERQ was cross-sectionally associated with smoking fewer cigarettes. Recent evidence has indicated that reappraising stress-related arousal improves cognitive performance and physiological reactivity (Jamieson et al., 2012; 2013). Evidence thus far suggests that the use of cognitive reappraisal in particular as a self-regulation strategy may have positive implications for smoking behavior, including cigarette craving.