Although there is good news about smoking -- only 14 percent of Americans smoke, the lowest number ever, according to a 2017 National Health Interview Survey -- challenges remain. In a given year, more than 40 percent of smokers make no attempt to quit. For those who do, it can take many tries -- estimates vary from six to 30 -- before they succeed, if they ever do. If more smokers are to succeed in staying quit, a better understanding of the factors that hinder them from meeting smoking cessation milestones is needed.
In the November issue of the Journal of Consulting and Clinical Psychology, investigators at the Medical University of South Carolina (MUSC) identify cessation fatigue -- emotional exhaustion and reduced coping resources due to attempts to quit smoking or stay quit -- as one such factor.
"We all know the stories of people who have tried and tried but repeatedly failed. Think about the cognitive and emotional toll that must take," explains Matthew J. Carpenter, Ph.D., professor in the Department of Psychiatry and Behavioral Sciences at MUSC, a member of the Hollings Cancer Center and senior author on the article. "People get burnt out or exhausted from making repeated attempts and this study shows that has an effect on smoking cessation milestones."
In the study, cessation fatigue, which was measured with a new multi-item scale for emotional exhaustion developed at MUSC, increased in the first six weeks of a quit attempt before plateauing. High cessation fatigue scores also predicted worse performance on important cessation milestones, such as time to quit attempt (for smokers who intended to quit) and relapse (for those already making a quit attempt). For both groups, those with higher scores on the emotional exhaustion scale, indicating a greater degree of cessation fatigue, were significantly less likely to have gone a full week without smoking at two months.
Why is this important? First, because cessation fatigue seems to be increasing just as other important predictors of relapse, such as withdrawal symptoms, are abating. Second, it offers a novel target for intervention strategies and helps identify those who would be most likely to benefit from those interventions.
"This could be like a triage where you could quickly give it to people and see where they're at on this fatigue level," says Bryan W. Heckman, Ph.D., assistant professor in the Department of Psychiatry and Behavioral Sciences at MUSC and first author on the article. "If they're high or elevated, then that might be an intervention point to help them reduce their fatigue."
A number of existing and developing intervention strategies could help reduce cessation fatigue. Pharmacological therapies already used in smoking cessation could be timed to ease cessation fatigue. Mobile health (mHealth) applications, which can reduce the logistical burden and stress of making a quit attempt, could be especially useful. For instance, Heckman is testing whether locations that prompt increases in urges to smoke can be programmed into an app using the GPS available on cell phones. When smokers making a quit attempt approach a location that they associate with smoking, they would automatically receive a push notification from the app to take a nicotine lozenge to help stave off the temptation to smoke.
"If we automate treatment using apps and reduce the amount of effort that people need to put into quit attempts, that could end up reducing fatigue over time," says Heckman.
"Using these mHealth technologies, we both automate and personalize," adds Carpenter. "Instead of giving blanket advice to twenty people, we can tailor therapy to each individual."z
Next steps will be a longer-term study of the effects of cessation fatigue on quit attempts. Once cessation fatigue and its time course are better understood, more mHealth interventions targeting it will be developed and tested. Heckman and Carpenter also think it would be worthwhile to explore cessation fatigue in those making quit attempts for different substances of abuse or in those making other efforts at lifestyle change.
"I don't think this is just about addictions and smoking," says Carpenter. "This is about health behavior change. Think about anything that anybody tries to do that's hard. It takes time. To say that you're going to be one hundred percent committed on every day of your life in that attempt is folly. It's a process. It takes a toll on you. Now we can look at this as a process and quantify that fatigue over time and see how it matters."
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