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Effects of the guided body scan on cigarette cravings and nicotine
withdrawal symptoms, and an exploration of distraction as the
underlying mechanism
Sally Playle
Thesis submitted for the award of Doctor of Philosophy (PhD)
Department of Psychology
Faculty of Health and Medical Sciences
University of Surrey
Date: 31.01.2017
ABSTRACT
The aim of this thesis was to investigate the effects of the guided body scan on
cigarette cravings and nicotine withdrawal symptoms in temporarily abstinent
smokers. In light of evidence that a combination of pharmacotherapy and behavioural
support can result in even greater success rates than either strategy alone (Stead &
Lancaster, 2012), study one was the first randomised placebo-controlled trial to
examine how the body scan interacts with traditional nicotine replacement therapy.
Unfortunately, the magnitude of an anti-placebo effect meant that neither the nicotine
nor placebo patches had an effect on ratings of withdrawal symptoms and tobacco
cravings. The results did however show that the body scan produced significant post
intervention reductions relative to baseline, whilst unexpectedly finding that the
control audio also yielded similar levels of efficacy. This cast doubt on the theory that
the body scan reduces cravings and withdrawal symptoms via the promotion of non-
judgemental acceptance of thoughts and feelings, although the idea that both audio
interventions acted as a form of cognitive distraction seemed more plausible. The
secondary aim was therefore to explore whether cognitive distraction is a mechanism
underlying the efficacy of the body scan, with study three comparing a guided body
scan to two distraction tasks. The results indicated that relative to baseline, all three
interventions produced reductions in withdrawal symptoms up to 10 minutes post
task, however the body scan out performed the two distraction tasks in reducing the
desire to smoke. This implies that whilst the processes associated with cigarette
withdrawal might be vulnerable to disruption via cognitive distraction, the desire for a
cigarette is less susceptible. Instead, the body scan may provide additional benefits via
the moderation of negative affect or a relaxation response.
i
STATEMENT OF ORIGINALITY
This thesis and the work to which it refers are the results of my own efforts. Any ideas,
data, images or text resulting from the work of others (whether published or
unpublished) are fully identified as such within the work and attributed to their
originator in the text, bibliography or in footnotes. This thesis has not been submitted
in whole or in part for any other academic degree or professional qualification. I
agree that the University has the right to submit my work to the plagiarism detection
service TurnitinUK for originality checks. Whether or not drafts have been so-
assessed, the University reserves the right to require an electronic version of the final
document (as submitted) for assessment as above.
ii
TABLE OF CONTENTS
ABSTRACT i
STATEMENT OF ORIGINALITY ii
TABLE OF CONTENTS iii
List of figures viii
List of tables ix
CHAPTER 1: SMOKING: EFFECTS ON HEALTH, CONSEQUENCES OF
NICOTINE AND ADDICITION, AND CURRENT STRATEGIES AND
APPROACHES TO SMOKING CESSATION
1.1 GENERAL INTRODUCTION…....……………………..................................1
1.2 SMOKING STATISTICS……………………………………………………..2
1.3 HEALTH EFFECTS…………………………………………………………..5
1.3.1 Pulmonary disease……………………………………………………..7
1.3.2 Cardiovascular disease…………………………………………...……9
1.3.3 Ischemic stroke……………………………………………………….12
1.4 NICOTINE AND DEPENDENCE…………………………………………..13
1.5 MODELS OF CRAVING……………………………………………………16
1.5.1 Conditioning models…………………………………………………16
1.5.2 Cognitive models……………………………………………………..18
1.6 STANDARD TREAMTENTS……………………………………………….25
1.6.1 Pharmaceuticals………………………………………………………25
1.6.2 Behavioural strategies………………………………………………..28
1.6.3 Cognitive strategies…………………………………………………..31
1.7 AIMS AND OBJECTIVES OF RESEARCH………………………………..35
iii
CHAPTER 2: MINDFULNESS DEFINITION & MECHANISMS
2.1 ORIGIN AND DEFINITIONS…………………………………………...….37
2.2 MINDFULNESS INTERVENTIONS FOR SMOKERS…………………....39
2.2.1 Mindfulness Based Stress Reduction (MBSR)…………………........39
2.2.2 Acceptance and Commitment Therapy (ACT)………………………41
2.2.3 Urge surfing…………………………………………………………..42
2.2.4 Body scan…………………………………………………………….44
2.3 MINDFULNESS MECHANISMS………………………………………......47
2.3.1 Cognitive flexibility and attention control…………………………...47
2.3.2 Affect/emotion regulation…………………………………………....51
CHAPTER 3: MINDFULNESS INTERVENTIONS FOR SMOKING
CESSATION: A SYSTEMATIC REVIEW WITH META ANALYSIS
3.1 INTRODUCTION……………………………………………………………58
3.2 OBJECTIVES………………………………………………………………..60
3.3 CRITERIA FOR INCLUSION………………………………………………60
3.3.1 Study design………………………….……………………………....60
3.3.2 Participants……………………………………………………….......60
3.3.3 Interventions………………………………………………………....61
3.3.4 Outcome measures…………………………………………………...61
3.4 SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES…………...61
3.5 DATA COLLECTION & SYNTHESIS……………………………………..62
3.6 RESULTS……………………………………………………….......…….…..71
3.6.1 Description of acute studies……………………………………….....71
3.6.2 Methodological quality of acute studies……………………………...73
3.6.3 Intervention efficacy of acute studies………………………………...75
3.6.4 Description of cessation studies……………………………………...77
3.6.5 Methodological quality of cessation studies………………………....79
3.6.6 Intervention efficacy of cessation studies………….…………….......83
3.7 DISCUSSION………………………………………………………………..88
3.8 FURTHER RESEARCH QUESTIONS……………………………....……...95
iv
CHAPTER 4 (STUDY 1): EXPLORATION OF THE SYNERGISTIC EFFECT
OF NICOTINE REPLACEMENT THERAPY AND A GUIDED BODY SCAN
ON CIGARETTE CRAVINGS AND NICOTINE WITHDRAWAL
4.1 INTRODUCTION………………………………………….....……………...97
4.2 METHODOLOGY……………………………………………....…………...99
4.2.1 Participants……………………...……………………………....……99
4.2.2 Design………………………………………………….....…….…….99
4.2.3 Interventions…………………………………………………..…….100
4.2.4 Measures…………………………………….………………………101
4.2.5 Procedure……………………………………….…………………...102
4.3 RESULTS…..………………………………………….………………....…106
4.3.1 Baseline comparisons........................................................................106
4.3.2 Data screening...................................................................................109
4.3.3 Changes in desire to smoke and withdrawal symptoms pre-audio
intervention........................................................................................109
4.3.4 Changes in desire to smoke and withdrawal symptoms post-audio
intervention........................................................................................111
4.3.5 Credibility of interventions................................................................114
4.4 DISCUSSION................................................................................................115
CHAPTER 5 (STUDY 2): THEORIES OF COGNITIVE DISTRACTION &
SEARCH FOR BODY SCAN COMPARABLE DISTRACTOR TASKS
5.1 INTRODUCTION..........................................................................................121
5.2 METHODOLOGY.........................................................................................129
5.2.1 Systematic search...............................................................................129
5.2.2 Distraction tasks.................................................................................132
5.2.3 Participants.........................................................................................135
5.2.4 Design.................................................................................................135
5.2.5 Measures.............................................................................................136
5.2.6 Procedure............................................................................................137
v
5.3 RESULTS.......................................................................................................138
5.3.1 Comparison of task ratings on post-task questionnaire items............138
5.3.2 Comparison of the body scan to the other tasks on all measures........143
5.4 DISCUSSION................................................................................................144
CHAPTER 6 (STUDY 3): COMPARISION OF THE GUIDED BODY SCAN
VERSUS TWO DISTRACTION TASKS ON CIGARETTE CRAVINGS &
WITHDRAWAL SYMPTOMS
6.1 INTRODUCTION..........................................................................................148
6.2 METHODOLOGY.........................................................................................150
6.2.1 Participants.........................................................................................150
6.2.2 Design.................................................................................................150
6.2.3 Interventions.......................................................................................151
6.2.4 Measures.............................................................................................152
6.2.5 Procedure............................................................................................153
6.3 RESULTS......................................................................................................155
6.3.1 Baseline comparisons.........................................................................155
6.3.2 Data screening....................................................................................158
6.3.3 Changes in strength of desire to smoke..............................................158
6.3.4 Changes withdrawal symptoms..........................................................160
6.3.4 Credibility of interventions................................................................161
6.4 DISCUSSION................................................................................................164
CHAPTER 7: CONCLUSIONS AND FUTURE DIRECTIONS
7.1 INTRODUCTION..........................................................................................170
7.2 SUMMARY OF EMPIRICAL STUDIES.....................................................172
7.2.1 Study 1...............................................................................................172
7.2.2 Study 2...............................................................................................174
7.2.3 Study 3...............................................................................................177
7.2.4 Summary of findings..........................................................................178
7.3 UNDERLYING MECHANISMS OF THE BODY SCAN...........................180
7.3.1 Cognitive distraction..........................................................................180
vi
7.3.2 Relaxation response...........................................................................182
7.3.3 Moderation of negative affect............................................................182
7.4 THE BODY SCAN AS A SMOKING INTERVENTION............................183
7.5 LIMITATIONS..............................................................................................188
7.5.1 Measurement issues...........................................................................188
7.5.2 Theoretical intervention issues..........................................................192
7.6 FUTURE RESEARCH..................................................................................193
7.7 CONCLUSIONS...........................................................................................195
REFERENCES.........................................................................................................197
APPENDICES
Appendix 1 Study 1: Clinical trials approval from the MHRA.............................233
Appendix 2 Study 1: Ethics approval....................................................................234
Appendix 3 Study 1: Poster advertisement............................................................235
Appendix 4 Guided body scan routine verbatim narrative....................................236
Appendix 5 Fagerström Test for Nicotine Dependence (FTND)..........................239
Appendix 6 Mood and Physical Symptoms Scale (MPSS)...................................240
Appendix 7 Study 1: Participant information sheet...............................................241
Appendix 8 Study 1: Participant consent form......................................................242
Appendix 9 Study 1 & 3: Demographics questionnaire........................................243
Appendix 10 Study 1: Rating interval schedule......................................................244
Appendix 11 Study 1: Participant feedback questionnaire......................................245
Appendix 12 Study 2: Ethics approval....................................................................246
Appendix 13 Study 2: Distraction task systematic literature search grid................247
Appendix 14 Study 2: Poster advertisement............................................................276
Appendix 15 Study 2: Post distraction task questionnaire.......................................277
Appendix 16 Study 2: Participant information sheet...............................................278
Appendix 17 Study 2 & 3: Participant consent form...............................................279
Appendix 18 Study 2: Demographics questionnaire................................................280
Appendix 19 Study 2: Individual distraction item figures.......................................281
Appendix 20 Study 3: Ethics approval....................................................................283
Appendix 21 Study 3: Poster advertisement............................................................284
Appendix 22 Study 3: Participant information sheet...............................................285
vii
Appendix 23 Study 3: Participant feedback questionnaire......................................286
Appendix 24 Study 3: Smoking cessation resources...............................................287
____________________________________________________________________
LIST OF FIGURES
_____________________________________________________________________
1.1 Overview of mechanisms by which cigarette smoking causes acute
cardiovascular event………………………………………………………….11
1.2 The biology of nicotine addiction…………………………………….………14
3.1 Flow diagram of study selection and exclusion process…………………......63
3.2 Risk of bias summary for cessation studies……………………………….....82
4.1 Rating schedule for MPSS items immediately before and after audio
intervention……………………………………………………………….....105
4.2 Changes in pre-audio intervention ratings of desire to smoke by patch.........110
4.3 Change in pre-audio intervention ratings for withdrawal symptoms by
patch...............................................................................................................111
4.4 Mean changes in desire to smoke ratings by group.......................................112
4.5 Mean changes in withdrawal symptom ratings by group...............................113
4.6 Non-pharmacological influences on responses to substance use………...…117
5.1 Mean rating of attention expenditure by task.................................................139
5.2 Mean ratings of difficulty by task..................................................................140
5.3 Mean rating of how relaxing participants found the tasks.............................141
5.4 Mean rating of how much participants enjoyed doing the tasks....................142
6.1 Mean change in ratings of desire to smoke by group.....................................159
6.2 Mean change in ratings of withdrawal symptoms by group..........................160
viii
_____________________________________________________________________
LIST OF TABLES
_____________________________________________________________________
1.1 Major Toxic Agents in Cigarette Smoke………………………………………5
1.2 Smoking attributable deaths amongst adults aged 35 and over in England in
2011……………………………………………………………………………6
1.3 Summary of major craving models…………………………………………..23
3.1 Characteristics of acute studies………………………………………………65
3.2 Characteristics of cessation studies…………...…………………..………….68
3.3 Forest plot of Relative Risk (with 95% confidence interval) for abstinence
versus relapse outcomes in cessation studies………………………………...86
4.1 Mean and standard deviation of demographic and smoking characteristics by
group...............................................................................................................106
4.2 Percentages for gender, marital status, occupation, ethnicity & desire to give
up smoking by group......................................................................................107
4.3 Mean and standard deviation of desire to smoke and MPSS withdrawal items
by group..........................................................................................................108
5.1 Summary of the number of distraction tasks per classification category.......131
5.2 Paired t-tests to compare the guided body scan to other tasks on measures of
attention, difficulty, relaxation and enjoyment..............................................143
6.1 Mean and standard deviation of demographic and smoking characteristics by
group...............................................................................................................155
6.2 Percentages for gender, marital status, occupation, ethnicity & desire to give
up smoking by group......................................................................................156
6.3 Mean and standard deviation of desire to smoke and MPSS withdrawal items
by group..........................................................................................................157
6.4 Mean, standard deviation and t-test results for desire to smoke ratings by time
point................................................................................................................159
6.5 Mean, standard deviation and t-test results for composite withdrawal symptom
ratings by time point......................................................................................161
ix
_____________________________________________________________________CHAPTER 1
SMOKING: EFFECTS ON HEALTH, CONSEQUENCES OF NICOTINE AND
ADDICITION, AND CURRENT STRATEGIES AND APPROACHES TO
SMOKING CESSATION
1.1 General Introduction
Despite a steady decline during the past 20 years, smoking remains the single biggest
preventable cause of ill-health in the UK, with deaths from smoking accounting for
more than the next six most common causes of preventable deaths combined (drug
use, road traffic accidents, other accidents or falls, preventable diabetes, suicide and
alcohol abuse; HM Government, 2011). With over 10 million active smokers and
approximately 67% wishing to quit at any one time (Lader, 2009), helping smokers to
achieve long-term cessation is crucial in tackling one of the most significant public
health challenges facing the UK and the world today.
Attempting to quit unaided has been found to result in only a 4% success rate at 12-
month follow-up (Hughes, Keely & Naud, 2004), however the use of nicotine
replacement therapy (NRT) can increase the chances of long-term abstinence by
between 50 – 70% (Stead, Perera, Bullen, Mant, Hartmann-Boyce, Cahill &
Lancaster, 2012), and a combination of pharmacotherapy and behavioural support can
result in even greater success rates of between 70 – 100% at 12 months post-quit
(Stead & Lancaster, 2012). Quitting smoking significantly reduces morbidity and
mortality, with the benefits of cessation at age 60, 50, 40 or 30 leading to a gain of
approximately 3, 6, 9 or 10 years of life respectively (Doll, Peto, Boreham &
Sutherland, 2004). In light of this, and in order to conduct effective research into
1
methods for aiding cessation, it is essential that we first understand nicotine addiction,
the behavioural mechanisms that maintain a smoking habit, and existing strategies for
quitting. This introductory chapter will therefore focus on current smoking statistics,
the effects of smoking on health, nicotine dependence and cravings, and both
pharmaceutical and non-pharmaceutical approaches to smoking cessation.
1.2 Smoking Statistics
In 2014, the Health and Social Care Information Centre (HSCIC) published a report
drawn from a variety of sources that outlined the most recent statistics regarding adult
smoking habits in England. The main source of data for smoking prevalence among
adults was the Opinions and Lifestyle, Smoking Habits Amongst Adults Survey 2012
(OPN; Office for National Statistics; ONS, 2013a), which revealed the following:
Among adults aged 16 and over, in England:
20% reported smoking in 2012, a rate that has remained largely unchanged in
recent years, compared with 26% in 2002, 39% in 1980 and 46% in 1974.
Unemployed people (39%) were around twice as likely to smoke as those
either in employment (21%) or economically inactive (17%).
Men were more likely to smoke than women (22% compared with 19%).
Those aged 20 to 24 and 25 to 34 reported the highest prevalence of cigarette
smoking (29% and 27% respectively), while those aged 60 and over reported
the lowest prevalence (13%).
Current smokers smoked an average of 12 cigarettes per day.
In 2008/9 two thirds (67%) of current smokers reported wanting to give up
smoking, with three quarters (75%) reporting having tried to give up smoking
at some point in the past.
2
In 2007, the British government published a Public Service Agreement (PSA), PSA
Delivery Agreement 18: Promote better health and wellbeing for all, which stated the
aim of reducing smoking prevalence among adults to 21% or less by the year 2010.
The prevalence of smokers subsequently declined year on year, and this target was
successfully met with only 20.3% of those responding to the 2010 General Lifestyle
Survey (ONS, 2012) classifying themselves as ‘current cigarette smokers’. A later
government white paper, Healthy Lives, Healthy People: A tobacco control plan for
England (HM Government, 2011) set out targets to reduce smoking prevalence even
further to 18.5% or less by 2015, and according to the latest live statistics from the
Smoking Toolkit Study (STS; 2015), a monthly cross sectional household interview
of 1,800 adults, cigarette smoking prevalence rates were already estimated to be down
to 18.5% by December 2014. This has been achieved via a number of different
strategies including restricting access to tobacco for young people, regulating
advertising and promotion of tobacco products, enforcing smoke free legislation,
encouraging cessation through health and social care professionals, supporting local
stop smoking services, and using taxation to make tobacco less affordable (HM
Government, 2011). In particular, tobacco prices have increased by 80.2% in the last
ten years, making it 22.1% less affordable (HSCIC, 2014).
As well as the personal cost of smoking (£18.9 billion was estimated to be spent on
tobacco in the UK in 2013; ONS, 2013b), the cost to the NHS of treating smoking
related illness and disease is also important to consider. Research by Callum, Boyle
and Sandford (2011) estimated the cost to be around £2.7 billion in 2006, which
represented 5% of adult hospital admission costs, 4% outpatients, 11% GP and 8%
practice nurse consultations, and 12% of prescription costs. Recent statistics from the
3
HSCIC (2014) for hospital admissions and deaths as a result of smoking revealed the
following:
Hospital admissions in England in 2012/13 among adults aged 35 and over:
There were approximately 1.6 million admissions for adults aged 35 and over
with a primary diagnosis of a disease that can be linked to smoking. This is
approximately 4,400 admissions per day on average. The annual number of
admissions has been rising steadily since 1996/97, when the number of such
admissions was approximately 1.1 million.
Around 460,900 hospital admissions were estimated to be attributable to
smoking. This accounts for 4% of all hospital admissions in this age group (35
years and over). It compares to 559,800 admissions in 2004/05, which is a
decrease of 18%.
The proportion of admissions attributable to smoking as a percentage of all
admissions was greater amongst men (6%) than women (3%).
In 2013, 17% (79,700) of all deaths of adults aged 35 and over were estimated
to be caused by smoking. This proportion is unchanged from 2005.
Aside from NHS costs, the overall financial liability of smoking to the economy is
estimated to be around £13.74 billion a year (Nash & Featherstone, 2010). This figure
is made up of losses of productivity as a result of smoking breaks, a loss in
economic output from people who die from smoking related
diseases or exposure to second hand smoke, increased absenteeism, the
costs of cleaning up cigarette butts and the cost of smoking related house fires. This
highlights how despite huge efforts by both the government and NHS to reduce
4
smoking rates in the UK via public health promotion campaigns and stop smoking
services, smoking remains a considerable economic and health burden that must
continue to be confronted.
1.3 Health Effects
Cigarettes provide a highly efficient method of conveying nicotine to the lungs, where
it is rapidly absorbed into the bloodstream, delivering a high-concentration ‘bolus’ of
nicotine to the brain via arterial circulation (West & Shiffman, 2007). However,
whilst nicotine is the primary addictive agent in cigarette smoke, most of the toxicity
from tobacco smoking originates from other components (Benowitz, 2009). Table 1.1
below provides a summary of the major toxic agents and the effects each one has on
the body.
Table 1.1
Major Toxic Agents in Cigarette Smoke
Agent
Concentration/ Non-
Filter Cigarette Toxicity
Carbon monoxide 10-23 mg Binds to haemoglobin, inhibits respiration
Ammonia 10-130 μg Irritation of respiratory tract
Nitrogen oxide 100-600 μg Inflammation of the lung
Hydrogen cyanide 400-500 μg Highly ciliatoxic, inhibits lung clearance
Hydrogen sulfide 10-90 μg Irritation of respiratory tract
Acrolein 60-140 μg Ciliatoxic, inhibits lung clearance
Methanol 100-250 μg Toxic upon inhalation and ingestion
Pyridine 16-40 μg Irritates respiratory tract
Nicotine 1.0-3.0 mg Induces dependence, affects cardiovascular and
endocrine systems
Phenol 80-160 μg Tumour promoter in laboratory animals
Catechol 200-400 μg Cocarcinogen in laboratory animals
Aniline 360-655 μg Forms methemoglobin, and this affects respiration
5
Maleic hydrazide 1.16 μg Mutagenic agent
Source: Hoffman & Hoffman (2001)
In terms of the long-term effects of smoking, Doll (1998) wrote a paper on smoking
from a historical perspective and reported how there has been medical evidence of the
damage caused by smoking accumulating for around 200 years; first in relation to
cancers of the lip and mouth, and later to lung cancer and vascular disease. This early
evidence was mainly ignored right up until the publication of a few case control
studies linking smoking to lung cancer in the 1950s (Doll & Hill, 1950; 1952; 1954),
and since then it has become apparent that smoking has disastrous effects on almost
all major organs, and has been implicated in the pathogenesis or exacerbation of many
chronic diseases (West & Shiffman, 2007). Table 1.2 below presents a summary of
cigarette smoking related mortality in England in 2011, followed by a discussion of
the more common causes of death and disease.
Table 1.2
Smoking attributable deaths among adults aged 35 and over in England in 2011
Men Women
Observed Deaths
Attributable number
%
Observed Deaths
Attributable number %
All deaths which can be caused by smoking 122,270 47,300 39 116,031 31,800 27
Cancers 37,758 23,600 63 29,149 13,700 47Trachea, Lung, Bronchus 15,694 13,700 87 12,449 9,300 74Upper respiratory sites 1,207 900 73 660 300 51Larynx 519 400 81 121 100 76Oesophagus 4,179 2,900 69 2,012 1,200 62Other 16,159 5,800 29 13,907 2,800 17
Respiratory diseases 21,931 11,900 54 24,846 10,700 43Chronic obstructive lung disease 716 600 89 452 400 82Chronic airway obstruction 11,129 8,800 79 10,544 8,200 78Pneumonia, influenza 10,086 2,400 24 13,850 2,100 15
Circulatory diseases 61,436 11,200 18 61,008 7,000 11Other heart disease 8,655 1,600 18 12,129 1,300 11Ischaemic heart disease 34,908 5,600 16 24,815 2,800 11
6
Other arterial disease 1,008 200 17 1,430 300 19Aortic aneurysm 3,434 2,200 63 2,335 1,300 57
Source: Mortality Statistics Extract, 2011 (HSCIC, 2014)
1.3.1 Pulmonary disease
Chronic Obstructive Pulmonary Disorder (COPD)
Smoking is known to be the most important cause of COPD (Mannino, 2002), with
the World Health Organisation (WHO) estimating that up to 73% of COPD mortality
in high-income countries is directly related to smoking (Lopez, Mathers, Ezzati,
Jamison, & Murray, 2006). The airway limitations associated with COPD are
characterised by anatomic and functional lesions, including emphysema, small airway
remodelling, mucus overproduction and chronic bronchitis (Churg, Cosio & Wright,
2008). The primary cause of this progressive airflow limitation is the abnormal
inflammatory response of the lungs associated with the noxious particles present in
cigarette smoke (Devereux, 2010).
A large prospective cohort study by Lundbäck, Lindberg, Lindström, Rönmark,
Jonsson, Jönsson, Larsson, Andersson, Sandström and Larsson (2003) used data from
Obstructive Lung Disease in Northern Sweden Studies (OLIN), which started as a
prevalence study in 1986. A randomly selected sample of 1,237 participants were
invited to take part in a structured interview and lung function test, and the authors
consequently report that approximately 50% of the smokers aged 65 and over had
already developed symptoms of COPD. They argue that the criteria for measuring and
diagnosing COPD had previously been ineffective and that the earlier estimation that
between 15-20% of smokers were likely to go on to develop the disease (American
Thoracic Society, 1995; Rijcken & Britton, 1998) was a vast underestimation.
Lung cancer
7
The first major epidemiological study in England to strongly support a link between
the number of cigarettes smoked and the risk of developing cancer of the lung was by
Doll and Hill (1950), who came to this conclusion through examining interviews and
diagnoses of patients in 20 London hospitals. At the request of the Medical Research
Council, they went on to conduct a parallel study to identify British doctors who
smoked, and within two and a half years of first contact, they discovered that many of
those doctors who smoked were dying of lung cancer (Doll & Hill, 1954). A review
paper looking at the trends in rates of smoking, smoking cessation and lung cancer by
Peto, Darby, Deo, Silcocks, Whitley and Doll (2000) used data from the original 1950
case-control study (Doll & Hill, 1952) and compared it to a case-control study
conducted in 1990 (Darby, Whitley, Silcocks, Thakrar, Green, Lomas, Miles, Reeves,
Fearn & Doll, 1998). In 1950, the cumulative risk of dying from lung cancer before
the age of 75 for men was just 6% compared with 16% in 1990. For women the
cumulative risk was only 1% in 1950 compared with 10% in 1990.
The authors argue that the most plausible explanation for this increase in relative risk,
despite a significant reduction in tar yields and a decrease in smoking prevalence, is
that as lung cancer mainly occurs after the age of 55, continuing smokers aged
between 55 and 74 years in 1950 were less likely to have smoked a substantial
number of cigarettes throughout adult life than current smokers in 1990. The review
does however conclude that smoking cessation before middle age avoids more than
90% of the risk of lung cancer associated with tobacco, and even stopping well into
middle age avoids most of the subsequent risk. Furthermore, widespread smoking
cessation has already halved lung cancer deaths compared with what would have been
expected had former smokers continued to smoke.
8
1.3.2 Cardiovascular disease
Coronary Heart Disease (CHD)
According to Ambrose and Barua (2004), the exact toxic components of tobacco
smoke and the mechanisms responsible for cardiovascular disease and dysfunction are
largely unknown. They assert that smoking is however known to increase
inflammation, thrombosis and oxidation of lipoprotein cholesterol, and that exposure
to smoke increases oxidative stress, which has the potential to initiate an adverse
cardiovascular event. In terms of the raised risk of CHD through smoking, Kannel,
McGee & Gordon (1976) report results from a longitudinal study which found that
smoking was a major antecedent of CHD, but while it was an important risk factor for
men, it appeared to be only a minor risk factor for women. A later analysis by Castelli
(1984) reports that on the whole, cigarette smokers were found to be around one and a
half times more likely to develop overt CHD, with the risk returning to that of a
person who has never smoked a year post cessation. Continuing to smoke however
was associated with a significant increase in the chances of suffering a major
cardiovascular episode or sudden death.
Myocardial Infarction (MI)
According to Benowitz (2003), three main constituents of tobacco have been
proposed as potential contributors to cardiovascular disease: nicotine, carbon
monoxide and oxidant gases. Nicotine is rapidly absorbed into the body when a
cigarette is smoked, and despite a half-life of just 2 hours, significant plasma nicotine
levels in regular smokers remain 24 hours a day (Benowitz, Jacob, Denaro & Jenkins,
9
1991). Nicotine causes an elevation in heart rate, and it is this persistent sympathetic
nervous system stimulation that may contribute to cardiovascular disease.
Carbon monoxide is thought to be a risk factor because it binds to haemoglobin
thereby reducing oxygen carrying capacity and impeding oxygen release. In response
to this, red blood cells mass together creating a state of hypoxemia, increasing blood
viscosity and causing a hypercoagulable state. High levels of oxidising chemicals and
free radicals are inhaled through the combustion of tobacco, and when they enter the
circulatory system they decrease antioxidant enzyme activity and deplete endogenous
antioxidant levels in the blood (Das, 2003). Consequently, this oxidative stress is
linked to a number of antecedent risk factors for cardiovascular disease such as
inflammation, endothelial dysfunction, lipid abnormalities and platelet activation
(Burke & FitzGerald, 2003). A summary of the mechanisms by which cigarettes cause
acute cardiovascular events can be seen in figure 1.1.
10
Figure 1.1 Overview of mechanisms by which cigarette smoking causes acute cardiovascular events (Benowitz, 2003).
NICOTINECARBON
MONOXIDEGLYCOPROTEINSOXIDANT GASES
OTHER COMBUSTION PRODUCTS
CNS Activation
Reduced Oxygen
Availability Platelet Activation/Thrombosis
HR BP
Myocardial Contractility
Coronary Vasoconstriction
Increased Myocardial Oxygen Demand
Reduced Myocardial Oxygen Supply
Myocardial IschemiaMyocardial Infarction
Sudden Death
11
A prospective cohort study by Prescott, Hippe, Schnohr, Hein and Vestbo (1998) of
almost 25,000 people from the pooled data of three population studies conducted in
Copenhagen found that compared with non-smokers, current female smokers had a
relative risk of myocardial infarction of 2.24 (95% Confidence Interval [CI] 1.85-
2.71) and current male smokers 1.43 (95% CI 1.26-1.62). The risk of MI increased
with tobacco consumption irrespective of sex, but the increased risk to women
compared to men remained the same despite adjustments and controlling for age and a
number of other major cardiovascular risk factors such as blood pressure, cholesterol
levels, diabetes, or body mass index (BMI). The authors suggest that women are more
sensitive to the harmful effects of smoking through the interaction of the constituents
of tobacco smoke and hormonal factors. Quitting smoking however has been found to
reduce the risk of MI by up to 50% within the first year of cessation (US Department
of Health and Human Services, 1994).
1.3.3 Ischemic stroke
The relationship between smoking and the risk of suffering a stroke is still relatively
unclear, although it has been proposed that smoking increases arterial stiffness, which
subsequently leads to elevated blood pressure, increased hypertension and stress on
smaller arties (Narkiewicz, Kjeldsen & Hedner, 2005). Wolf, D'Agostino, Kannel,
Bonita and Belanger (1988) published one of the earliest studies to definitively link
smoking to an increased risk of ischemic stroke. They used data from the Framingham
study, which has followed a cohort of 5,209 men and women living in Framingham,
Massachusetts since 1948 via bi-annual clinical examinations and the constant
monitoring of morbidity and mortality. They found smoking to be a significant
independent contributor to the risk of suffering a stroke by up to 68%. Furthermore,
12
the risk increased with the number of cigarettes smoked, with heavy smokers carrying
twice the risk of light smokers. This increased risk has been found to exist for both
men (Abbott, Yin, Reed & Yano, 1986) and women (Colditz, Bonita, Stampfer,
Willett, Rosner, Speizer & Hennekens, 1988). Smoking cessation however leads to a
reduced risk of stroke in a relatively short time (within 6 to 24 months), and the risk is
the same as that of a non-smoker by five years (Shinton & Beevers, 1989).
To summarise, smoking remains a significant global cause of premature death and
chronic disease. Strong epidemiological evidence suggests that the number of years
smoking and the amount of cigarettes smoked contribute to an increased chance of
developing a smoking related illness, but that quitting at any point can substantially
reduce the risk.
1.4 Nicotine & Dependence
According to the American Psychiatric Association (APA; 2013), tobacco dependence
is characterised by persistent use despite an awareness of the associated harm, using
in greater amounts than intended, difficulty quitting despite a desire to, and the
presence of withdrawal symptoms in its absence. The symptoms of nicotine
withdrawal were first summarised in the Diagnostic and Statistical Manual, DSM-IV
(APA, 1994) as follows:
In persons who have been using nicotine-delivering products on a daily basis
for at least several weeks, cravings and the following signs may be observed:
Dysphoric or depressed mood, insomnia, irritability, frustration or anger,
anxiety, difficulty concentrating, restlessness, increased heart rate, increased
appetite or weight gain.
13
Dependence is acquired and maintained through a combination of pharmacological,
psychological, genetic, social and environmental factors, with nicotine being the
primary determinant for smoking behaviour to persist (Perkins, Conklin & Levine,
2008). Nicotine alleviate cravings via the enhancement of mood, both directly and
through the relief of tobacco withdrawal symptoms, and by boosting mental and
physical functions (Benowitz, 2010). See figure 1.2 below for a summary of the
biology of nicotine addiction:
Figure 1.2 The biology of nicotine addiction
(Benowitz, 2010)
Tobacco Product
Smoking behaviour
Neurotransmitter release
Reinforcement
Enhanced performanceMood modulation
Lower body weightReversal of withdrawal
symptomsSelf-medication
Metabolism
Environmental Influences
Nicotine cholinergic receptors
Factors affecting susceptibility:
AgeGenderGenetic predispositionPsychiatric disorderSubstance abuse
Nicotine in body
Reduced tolerance
14
As shown in figure 1.2, when nicotine in the blood reaches the brain it stimulates the
nicotinic cholinergic receptors that release a variety of neurotransmitters, including
most critically dopamine (Wonnacott, 1997). Dopamine signals a pleasurable
experience and produces the reinforcing effect that sustains tobacco addiction
(Nestler, 2005). In terms of the chronic impact of repeated exposure to nicotine,
neuroadaptation occurs whereby the brain develops a tolerance to the effects of
nicotine as nicotine receptors become desensitised (Watkins, Koob & Markou, 2000).
Cravings and withdrawal begin to occur when desensitised nicotine receptors become
responsive again during abstinence, and it is only via the binding of nicotine to these
receptors through smoking that symptoms are alleviated (Benowitz, 2010). This
suggests that normal levels of smoking maintain a state of desensitisation thus
avoiding any cravings and withdrawal symptoms, and consequently reinforces the
rewarding effects of nicotine intake.
Whilst it is not disputed that nicotine has a reinforcing effect, and the neurological
basis of nicotine dependence is important to understand, it only provides a very
simplistic view of tobacco addiction. For example, it does not account for the reasons
why nicotine replacement therapy does not fully prevent the desire for a cigarette
(despite relieving tobacco withdrawal symptoms), or the importance of environmental
cues and contexts in prompting a craving episode in the absence of acute withdrawal
symptoms. In light of this, the origin of ‘craving’ theories and an overview of the
major models associated with the concept will now be discussed in more detail.
15
1.5. Models of Craving
The concept of craving and how to define it has been historically controversial, with
the term falling in and out of favour over the years. In 1954 the World Health
Organisation (WHO; 1955) met specifically to determine how it should be used in
relation to alcohol addiction, and proposed replacing the everyday understanding of
craving as an “urgent and overpowering desire” with the new terms “physical
dependence” (withdrawal symptoms) and “pathological desire” (general craving once
withdrawal symptoms have dissipated). However despite their efforts to remove the
term craving from addiction discourse, it persisted in the literature mainly due to its
central role in medical models of alcoholism with the focus being on physical
dependence (Skinner & Aubin, 2010). In the 1970s and 80s new behavioural models
began challenging the traditional medical models by providing evidence from
observable behaviour rather than just measuring physical symptoms (e.g. Siegel,
1975; Marlatt, 1976; Leventhal & Cleary, 1980). As the term continued to be used,
the US National Institute on Drug Abuse (NIDA) called another meeting in 1991with
the aim of providing an agreement on the nature and value of the concept of craving.
They again failed to reach any kind of theoretical consensus, and despite the absence
of an agreed definition it still remains firmly at the heart of addiction theory today.
The most relevant and significant models of craving will now be discussed in more
detail.
1.5.1 Conditioning Models
Withdrawal Model
This model argues that the primary motivation of drug seeking behaviour is to escape
from the negative consequences of withdrawal symptoms (Wikler, 1948). Cravings
occur in response to both the emergence of withdrawal symptoms and in response to
16
environmental cues, with Drummond (2000) expanding on the model by proposing
the distinction between “cue-elicited cravings” (a conditioned response) and
“withdrawal related cravings” (an unconditioned response). Withdrawal can also be
conditioned, even after an extended period of abstinence. For example O’Brien (1975)
discusses a patient who had been incarcerated and without heroin for six months, and
who was completely free of withdrawal symptoms and cravings. Upon leaving prison
on the bus home, the man starts to think about drugs and begins to experience severe
withdrawal symptoms when passing an area he used to frequent when seeking to buy
drugs in a withdrawn state. He gets off the bus, buys drugs and quickly obtains relief.
The next day he begins to experience craving and withdrawal again, so the drug
taking cycle of re-addiction begins anew. As argued by Drummond (2000), the cue-
elicited cravings are much more of a threat to relapse than general withdrawal
cravings due to the availability and accessibility to the substance being craved. To
summarise, the central hypothesis holds that over the course of many episodes (i.e.
pairings) with drug taking, neutral environmental stimuli develop the ability to elicit a
conditioned response that resembles withdrawal symptoms, thereby prompting drug-
seeking behaviour. The model does not however account for instances where cravings
are not prompted or accompanied by withdrawal symptoms, as Kozlowski and
Wilkinson (1987) argue, although withdrawal may elicits craving, not all craving is
based on withdrawal.
Incentive Model
As opposed to withdrawal theories that emphasise negative reinforcement and the
central role of withdrawal symptoms, the incentive model (or conditioned drug-like
model; Stewart, de Wit and Eikelboom, 1984) focuses on the process of positive
17
reinforcement and conditioned reward. It posits that an environmental stimulus that is
regularly paired with drug taking becomes conditioned over time, and may itself
provoke the same physiological and psychological responses as taking the drug. If
drug taking doesn’t happen, cravings occur in an effort to promote drug-seeking
behaviour in order to experience the positive hedonistic effects as a reward. Later
neurological evidence to support this theory suggests that the drug seeking desire
stems from the expectation of reward that elicits the release of dopamine (Spanagel &
Weiss, 1999). One issue with the incentive model is the existence of individuals who
have a history of drug dependence, with all of the associated pleasurable experiences,
but who do not experience craving episodes (Skinner & Aubin, 2010). Furthermore, it
is likely that negative memories of past drug use exist for both those who crave and
those who don’t, so focusing purely on positive reinforcement raises questions of
validity.
1.5.2 Cognitive Models
Outcome expectancy model / Cognitive social learning model
Unlike conditioning models that view cravings as stemming from autonomic primal
drives, cognitive models base their theories on the operation of higher order
information processing systems within a framework of social learning constructs.
Whilst focusing on relapse and relapse prevention, Marlatt’s (1985) outcome
expectancy model argues that cravings are generated through exposure to drug related
environmental cues that trigger an outcome expectation response. In other words, if
the outcome expectancy is positive, the person believes there will be a positive effect
from smoking (e.g. relief from the discomfort of withdrawal). When the expectation is
negative however, the person believes there will be a negative effect of smoking (e.g.
18
cost of tobacco, damage to health). The model makes a further distinction between
‘cravings’ and ‘urges’, with cravings defined as the desire for a positive outcome that
in turn may trigger an urge, and an urge is defined as the intent to engage in drug use.
This suggests that craving alone may not be sufficient to cause drug use, and that a
smoker can desire a cigarette without it leading to action. The concept of self-efficacy
is also a central feature of the model, which posits that in high-risk situations, levels
of self-efficacy in relation to a person’s ability to resist the urge to smoke mediates
the risk of relapse. For example the risk of relapse is highest when there is a positive
outcome expectancy combined with low self-efficacy. Marlatt (1985) also argued that
cravings and self-efficacy were reciprocal in that high levels of cravings even have
the ability to undermine high self-efficacy, with the availability of effective coping
skills also playing a central role in resisting the urge to smoke.
In terms of the usefulness of the model in the development of relapse prevention
strategies, Haaga and Stewart (1992) found that smokers who reported a moderate
level of self-efficacy for relapse (SER) remained abstinent significantly longer than
those with either low or high reported SER. They conclude that levels need to be high
enough to not lose hope if temporary relapse does occur, but not so high that smokers
believe that they are resilient to temptation thus increasing the chances of
experimentation. Niaura (2000) also examined the mediating role of efficacy versus
urges in both a lab based cue exposure experiment and subsequent 6-month
abstinence rates. He found that while efficacy had a significant direct impact on
abstinence rates, urges had an indirect effect on smoking outcomes via efficacy.
Niaura concluded that while efficacy expectation plays a central role in mediating a
19
smoker’s response to both high-risk cue exposure situations and longer-term smoking
outcomes, the relationship between urges and outcome expectancy is still not clear.
Dual affect model
Incorporating elements from earlier conditioning models of craving, the dual affect
model (Baker, Morse & Sherman, 1987) proposes that cravings or urges are a
complex emotional processing system that affects the likelihood of consuming drugs.
Cravings are elicited by two affect networks; the positive affect urge network that
responds to information received from drug cues prompting an appetitive response
(much like the incentive model), and the negative affective urge network that
responds to negative stimuli, affect or withdrawal (much like the withdrawal model).
The two systems are also proposed to be mutually inhibiting in that a positive urge
response will prevent a negative urge response and may explain why cravings and
relapse are often associated with both positive and negative mood states (Drummond,
2001). To summarise, the model is useful in that it introduces the concept of viewing
cue reactivity in relation to mood states, but a major flaw is highlighted by the work
of Tiffany and Drobes (1991) who found that in the absence of drug related cues, urge
to smoke was not greatly affected by the induction of positive mood.
Cognitive processing model
The cognitive processing model (Tiffany, 1999) maintains that drug use, such as
habitual smoking, is an automatic process that mostly occurs without any effort or
conscious awareness. Craving is viewed as a non-automatic cognitive process that
occurs in response to a voluntary or involuntary obstacle blocking the automatized
smoking behaviour, and requires cognitive effort and awareness. This idea is
20
supported by various studies looking at cognitive task performance in abstinent and
non-abstinent smokers, with the results indicating that task performance is impaired in
the nicotine deprived groups compared with non-deprived controls (e.g. Gross, Jarvik
& Rosenblatt, 1993; Parrott, Garnham, Wesnes & Pincock, 1996; Cepeda-Benito &
Tiffany, 1996). Deprived smokers have also been found to have an attentional bias
towards smoking related stimuli (Sayette, 2004), and also explains why the risk of
relapse is higher for those in a craving state, with craving levels positively correlated
with a focus on smoking stimuli. Craving is not however required for either drug
seeking or use, as the model argues that the processes controlling craving are
independent of those controlling consumption. During drug cue exposure, cravings
are rarely cited as the cause of relapse (Tiffany & Conklin, 2000), with the model
asserting that mental schemas of past drug use are activated during cue exposure so
that relapse can occur in the absence of effort or intention. This also helps to explain
how relapse can occur long after withdrawal symptoms have gone.
Elaborated intrusion theory of desire
Kavanagh, Andrade and May (2005) proposed the elaborated intrusion (EI) theory of
desire, which maps both the emotional and cognitive processes that occur during
desire, and places particular importance on the role of mental imagery in sustaining
the sensory and affective elements of desire in consciousness. They posit that
(apparently) spontaneous intrusive thoughts, such as the desire for a cigarette, may
arise while attention is directed to concurrent cognitive tasks, and may manifest in the
form of images, verbal fragments or simply an implicit awareness. The intrusive
thought may stem from episodic, semantic or conditioned associations to internal or
external cues, which the authors separate into five types: physiological deficit states
21
(e.g. desensitised nicotine receptors), negative affect (e.g. withdrawal symptoms),
external cues (e.g. seeing smoking paraphernalia, smelling tobacco smoke),
anticipatory responses to the target (relief from withdrawal, satisfied desire), and
other cognitive activity. The authors argue that intrusive thoughts emerge fully into
consciousness if elaboration occurs via actively controlled cognitive processing;
associated affective responses are triggered, and salient target information retained in
working memory is sought. For example, the desire for a cigarette (intrusive thought)
may prompt the smoker to imagine smoking the cigarette, think about past episodes of
smoking, and the availability of tobacco (elaboration). The likelihood of the intrusive
thought being elaborated upon depends upon how strongly the smoker identifies with
their elaborated rumination of sensory images, and the subsequent level of attention
directed to target relevant stimuli. This progressive elaboration, particularly in the
form of mental imagery, is viewed as a central process underlying the way that desires
persist during a craving episode.
Conversely however, if the intrusive thought is not attended to or retained in working
memory, it becomes susceptible to distraction by competing salient stimuli and
elaboration does not occur. In this way, the theory suggests that while desire may
make consumption more likely to occur, it is not an inevitable outcome due to the
vulnerability of both the intrusive thought and elaboration processes to disruption. It
is this theory, and the idea that smokers can be distracted from their cravings via
competing tasks that recruit the same high-level cognitive processes, which forms the
basis of the hypotheses of this thesis. The EI theory of desire will therefore be
discussed in depth in chapters five and six in relation to tobacco cravings and
distraction.
22
Table 1.3
Summary of the major craving models
Model Addiction Key authors HypothesesConditioning based models Conditioned withdrawal model Drugs, alcohol Winkler (1948) Craving occurs to in response to aversive withdrawal discomfort
or drug use cues, which can be conditioned.Compensatory response model Drugs, alcohol Siegel (1989) Drug cues are conditioned, and craving occurs as an aversive
response in order to escape the discomfort of tolerance (seen as a decrease in pleasure).
Opponent-process model Drugs Solomon & Corbit (1974)
The CNS automatically responds to the discomfort of withdrawal symptoms by stimulating cravings to prompt drug use.
Incentive model / Conditioned drug-like model
Drugs, alcohol Stewart, de Wit & Eikelboom (1984)
Craving is motivated by the positive memories of experiencing pleasurable effects from drug taking
Incentive sensitization model Drugs Robinson & Berridge (2001)
Differentiates 'wanting' a drug (a sensitized incentive motivational system) from 'liking' a drug (craving)
Cue-reactivity model Drugs, alcohol Drummond, Tiffany, Glautier & Remington (1995)
Cravings based on cue reactivity can be autonomic, cognitive-symbolic or behavioural and do not necessarily lead to drug seeking behaviour
Cognitive based models Outcome expectancy model / Cognitive social learning theory
Alcohol Marlatt (1985); Marlatt & Gordon (1985)
Environmental cues prompt expectations relating to the positive and negative effects of consumption that influence both cravings (desire) and urges (intention).
Dual-affect model Tobacco Baker, Morse & Sherman (1987)
Craving occurs via the activation of mutually exclusive (and inhibitory) positive and negative affective processing networks.
Affective processing model of negative reinforcement
Tobacco Baker, Piper, McCarthy, Majeskie & Fiore (2004)
Negative affect interferes with a smoker’s ability to manage cravings in response to interoceptive and exteroceptive cues.
Cognitive labelling model Drugs Schachter & Singer (1962)
Craving is an emotion that occurs in response to drug related cues or withdrawal, that leads to physical arousal and the cognitive labelling of the response identifying the arousal as craving.
Continued…
23
Model Addiction Key authors Hypotheses
Cognitive based models continued…
Dynamic regulatory model Alcohol, tobacco
Niaura, Rohsenow, Binkoff, Monti, Pedraza & Abrams (1988)
Craving occurs via a combination of conditioned responses to drug cues, and levels of positive and negative affect. Drug use and relapse is mediated by coping skills and self-efficacy.
Cognitive processing model Drugs, alcohol, tobacco
Tiffany (1999) Drug use is an automatic, effortless process and craving occurs in response to an obstacle preventing drug consumption. Craving is seen as a non-automatic, effortful response.
Elaborated intrusion model Food, tobacco Kavanagh, Andrade & May (2005)
Drug related intrusive thoughts (in the form of mental imagery) are progressively elaborated upon via actively controlled cognitive processing of affective responses and salient target information retained in working memory.
Motivational models 1 Motivational model of alcohol use
Alcohol Cox & Klinger (1988) Craving is motivated by a desire to achieve an emotional state and is triggered by expectations, physiological need, memories of past drug taking behaviour and reinforcement from drug use.
Multidimensional ambivalence model
Drugs, alcohol Breiner, Stritzke & Lang (1999)
Craving and aversion cause ambivalence and represent competing neural systems that respond independently to a variety of triggers (e.g. biological reactivity, cues, personality, expectations).
Prime Theory Addictive substances
West (2006) Craving has two levels of motivation: impulses/inhibitions and motives. Cravings (or drives) originate from disturbance in the motivational structure that has been modified by substance use.
Adapted from Tiffany (1999), Drummond (2001) & Skinner & Aubin (2010)
1 Motivational models are not fully discussed in the text due to space limitations and a lack of direct relevance to the thesis, but are included here as they still provide an important contribution to the development of craving theories.
24
1.6 Standard treatments
There are many types of cessation aids and counselling services available to smokers
wishing to quit, however an analysis of the 1996 California Tobacco Survey by Zhu,
Melcer, Sun, Rosbrook and Pierce (2000) found that only 19.9% of a random sample
of 4,480 smokers who had tried to quit in the previous year, had sought some kind of
assistance. Furthermore, only 7% of those who tried to quit unassisted were abstinent
at the 12-month follow-up, compared to 15.2% who used assistance. In order to
facilitate a significant increase in cessation rates, smokers need information, access
and encouragement to seek assistance, as well as the availability of effective treatment
strategies. The range and efficacy of the most common pharmaceutical, behavioural
and cognitive approaches to cessation will now be discussed in more detail.
1.6.1 Pharmaceuticals
Nicotine Replacement Therapy (NRT)
The aim of NRT is to reduce the tobacco withdrawal symptoms associated with
smoking cessation through the replacement of nicotine without the vast number of
carcinogens and toxins produced via the combustion of tobacco (Fant, Owen &
Henningfield, 1999). There are a number of different nicotine delivery systems
available; they range from transdermal patches for slow release of nicotine over a
long period of time (16 hour and 24 hour in varying doses), to nicotine gums (2 mg
and 4 mg), lozenges, sublingual tablets and inhalators, oral and nasal sprays for quick
delivery of nicotine to the brain (West, McNeill & Raw, 2000). A large systematic
review by Stead et al (2012) examined at the efficacy of NRT through the analysis of
117 randomised controlled trials (RCTs) comparing various types of NRT with either
a placebo or non-NRT control group, with the data from over 50,000 participants
25
included in the analysis. They found that the risk ratio (RR) of remaining abstinent
through the use of any form of NRT compared with a control was 1.60 (95% CI 1.53
– 1.68). More specifically, the lowest pooled RR was for nicotine gum at 1.49 (95%
CI 1.40 – 1.60) and the highest was for nicotine nasal spray at 2.02 (95% CI 1.49 –
2.73), with nicotine patches yielding an RR of 1.64 (95% CI 1.52 – 1.78). The authors
conclude that all forms of NRT increase the chances of helping smokers to quit by
between 50 – 70%, that heavier smokers may benefit from higher doses of NRT, and
that it is effective with or without additional counselling and support. Furthermore,
there were very few adverse reactions from using NRT aside from mild skin irritation
from the patches and mild mouth irritation from the gums and lozenges.
Antidepressants
There are two antidepressant currently licensed as a prescriptive aid to smoking
cessation, namely bupropion (Zyban®) and the tricyclic, nortriptyline hydrochloride.
According to Hughes, Stead, Hartmann-Boyce, Cahill and Lancaster (2014), there are
three theories as to how antidepressants help smokers to quit; nicotine withdrawal can
produce depressive symptoms that are relieved by antidepressants, nicotine itself may
produce antidepressant effects that are substituted by antidepressants, and some
antidepressants may have an effect on neural pathways or receptors associated with
nicotine addiction. Bupropion is the most commonly used medication and has both
dopaminergic and adrenergic effects (Ascher, Cole, Colin, Feigher, Ferris, Fibiger,
Golden, Martin, Potter, Richelson & Sulser, 1995), and is a nicotine acetylcholinergic
receptor antagonist (Slemmer, Martin & Damaj, 2000). Through these biological
mechanisms it is thought to help smokers to quit by blocking the effects of nicotine
thereby relieving withdrawal symptoms, and/or alleviating depressed mood (Lerman,
26
Roth, Kaufmann, Audrain, Hawk, Liu, Niaura & Epstein, 2002). Nortriptyline
hydrochloride is the second most commonly prescribed antidepressant, and is known
to affect a number of neurotransmitter systems by increasing noradrenergic activity
via the blocking of norepinephrine reuptake, and to a lesser degree serotonin
(Corrigall, 1991).
Hughes et al (2014) conducted a systematic review with the aim of assessing both the
efficacy and safety of antidepressants to aid smoking cessation, which included 65
trials of bupropion and ten of nortriptyline. Using the data of over 13,000 participants,
they found that when used alone, bupropion significantly increased the chances of
long-term cessation (at least 6 months) with a RR of 1.62 (95% CI 1.49 – 1.76), as did
nortriptyline with an RR of 2.03 (95% CI 1.48 – 2.78). They conclude that
independent of their antidepressant effects, the two medications have similar efficacy
to traditional nicotine replacement therapy, and that they appeared to aid cessation
irrespective of whether or not participants had a history of depression, or depressive
symptoms upon quitting. Adverse reactions for bupropion included insomnia, dry
mouth, nausea, and seizures (1:1,000), and for nortriptyline included dry mouth,
constipation, nausea, and sedation. However, they rarely appear to be serious, or lead
to a cessation of medication.
Nicotine receptor partial agonists (nAChRs)
Varenicline (Chantix® or Champix®) and cytisine are both commercially available
forms of nAChRs that are thought to aid smoking cessation by providing both agonist
and antagonist effects on the a4ß2 nicotinic acetylcholine receptor (Nides, Oncken,
Gonzales, Rennard, Watsky, Anziano & Reeves, 2006). More specifically, they
27
counteract withdrawal symptoms via the maintenance of moderate dopamine levels
(acting as an agonist), and through the reduction of smoking satisfaction (acting as an
antagonist; Cahill, Stead & Lancaster, 2008). A comprehensive systematic review
conducted by Cahill, Stevens, Perera and Lancaster (2013) explored the efficacy of
different pharmacological interventions for smoking cessation compared with either a
placebo or other medication, which included 267 RCTs, covering more than 101,000
smokers. They report that varenicline was more effective in helping smokers to
achieve long-term abstinence (of 6 month or more) than nicotine patches alone with
an odds ratio (OR) of 1.51 (95% CI 1.22 – 1.87). They also found that cytisine was
effective in producing abstinence compared with a placebo, with a RR of 3.98 (95%
CI 2.01 – 7.87), although the analysis did result in a wide confidence interval.
Nicotine receptor partial agonists have previously been linked to a range of
psychiatric adverse events (Tonstad, Davies, Flammer, Russ & Hughes, 2010), and
serious cardiovascular events (Prochaska & Hilton, 2012). The systematic review by
Cahill et al (2013) however found only mild to moderate nausea which subsided over
time, and no significant differences in the occurrence of any serious adverse events
for varenicline compared with a placebo, and no serious adverse events reported at all
for cytisine.
1.6.2 Behavioural Strategies
Individual face-to-face counselling
A systematic review by Lancaster and Stead (2005) explored the efficacy of face-to-
face individual counselling in 30 randomised or quasi-randomised trials of smoking
cessation. The analysis of 22 trials comparing individual counselling to minimal
behavioural interventions suggested that individual counselling was more effective
28
than controls (RR 1.39; 95% CI 1.24 - 1.57). Additionally, a sub-analysis of four trials
where participants also received NRT showed the effect of counselling was small but
significant (RR 1.27; 95% CI 1.02 – 1.59), although there was no evidence of a
greater effect of intensive counselling compared with brief counselling (RR 0.96; 95%
CI 0.74 - 1.25). The authors conclude that face-to-face delivered individual
counselling can be effective in helping smokers to quit.
Group behaviour counselling
Stead and Lancaster (2005) conducted a further systematic review to compare group
based behaviour counselling with self-help materials, individual counselling or no
intervention (i.e. usual care or wait list controls). Thirteen randomised controlled trials
using self-help (without face-to-face instruction) met the inclusion criteria, with meta-
analysis indicating that group therapy almost doubled the chances of abstinence at the
six-month follow-up point (N = 4,375; RR 1.98; 95% CI 1.60 - 2.46). By contrast,
they found no evidence that group therapy was more effective than individual
counselling of a similar intensity, and statistical heterogeneity prevented the
estimation of pooled effects to compare group therapy to no intervention controls.
Furthermore, they report no extra benefit from providing group therapy in addition to
advice from a health professional or NRT.
Telephone support
Telephone support may be used in addition to individual therapy, self-help or
pharmacotherapy, and a review of randomised and quasi-randomised trials offering
proactive or reactive telephone counselling for smoking cessation was conducted by
Stead, Hartmann-Boyce and Lancaster (2013) to assess its efficacy. More than 24,000
29
participants were included in the analysis of smokers who contacted helplines, with
quit rates at the longest follow-up being significantly higher for those who were
randomised to receive multiple sessions of proactive counselling (RR 1.37; 95% CI
1.26 – 1.50). A further analysis of over 30,000 participants who received counselling
that was not initiated by calls to a helpline also showed increased quit rates compared
with controls (RR 1.27; 95% CI 1.20 – 1.36). The authors also report that
three or more calls increased the chances of abstinence compared
to one or two calls, and that a higher frequency of calls increased
the likelihood of quitting compared with standard self-help
materials, brief advice, or pharmacotherapy alone. This suggests
that proactive cessation counselling delivered via the telephone is
an effective and convenient route for accessing quit support, with
an increase in call frequency leading to improved abstinence
outcomes.
Online support
With an estimated 3.1 billion Internet users worldwide in 2015 (Internet Live Stats
2015), online interventions are an attractive vehicle for effecting behaviour change
due to the potentially wide audience and low cost. A systematic review by Civljak,
Stead, Hartmann-Boyce, Sheikh and Car (2013) found some evidence of the benefit of
tailored, interactive support as opposed to usual care or self help (RR 1.48; 95% CI
1.11 - 2.78), however the authors report high statistical heterogeneity, high risk of
bias and inconsistent effects. They concluded that despite the systematic review being
based on 28 trials, more research was required, however online support may be
30
effective when used in combination with other pharmacological or behavioural
interventions.
1.6.3 Cognitive Strategies
Thought Suppression
The frequency of smoking related thoughts has been found to be a significant barrier
to remaining abstinent (Herd, Boreland & Hyland, 2009), and the suppression of
intrusive thoughts is a commonly used technique reported by individuals trying to
control their thoughts and behaviours (Erskine, Georgiou & Kvavilashvili, 2010).
Current research concerning thought suppression as a technique for reducing cigarette
cravings, aiding smoking cessation and preventing smoking relapse is however
relatively mixed. Some studies report that the suppression of smoking related thoughts
could aid smoking cessation (e.g. Rodgers, Corbett, Bramley, Riddell, Wills, Lin &
Jones, 2005; Myers, MacPherson, Jones & Aarons, 2007), whereas others have found
no significant effect on desire to smoke or withdrawal symptoms (Erskine, Ussher,
Cropley, Elgindi, Zaman & Corlett, 2012) or that the request to suppress thoughts can
be counter-productive and actually increase the frequency of intrusive thoughts (e.g.
Salkovskis & Reynolds, 1994).
This paradoxical phenomenon is known as the White Bear effect (Wegner, 1994,
1997), which states that there are two processes that work to maintain cognitive
control: firstly the continual search for thoughts to produce a desired state of mind,
and secondly a concurrent monitoring process that signals failure when the state of
mind is not being produced. Therefore, when an individual attempts to gain cognitive
control of their thoughts via a thought suppression technique, they may actually cause
31
the very state of mind that they are trying to avoid. Based on the literature, it appears
that simply asking someone to suppress their thoughts about smoking is not sufficient
to stop the intrusive thoughts, and may do more harm than good as a smoking
cessation strategy.
Distraction
As opposed to thought suppression techniques, distraction may be more beneficial as
a strategy for preventing intrusive smoking related thoughts from occurring by
moving the focus of thought away from the unwanted target. However, despite plenty
of anecdotal evidence that distraction is considered a commonly used technique to
prevent smoking related thoughts and urges (e.g. O’Connell, Gerkovich, Cook,
Shiffman, Hickcox & Kakolewski, 1998; Brody, Mandelkern, Olmstead, Jou,
Tiongson, Allen, Scheibal, London, Monterosso, Tiffany, Korb, Gan & Cohen, 2007),
a literature search identified only one study looking directly at the effects of a
cognitive distraction task (compared with exercise) on desire to smoke and tobacco
withdrawal symptoms, and the authors report that there was no significant effect
(Daniel, Cropley & Fife-Schaw, 2006).
Cognitive distraction has been long used as an intervention in other fields of health
research, most notably in the domain of pain management (McCaul & Malott, 1984),
but also to treat anxiety (e.g. Lee, Henderson & Shum, 2004; Cooke, Chaboyer,
Schluter & Hiratos, 2005), distress (e.g. Windich-Biermeier, Sjoberg, Dale, Eshelman
& Guzzetta, 2007), in paediatric medicine (e.g. Sil, Dahlquist & Burns, 2013; Inal &
Kelleci, 2012) and dentistry (Wostratzky, Braun & Roth, 1988), however a lack of
research in the field of smoking cessation may in part be a result of the huge
32
heterogeneity in operationally defining “distraction” and therefore the wide variety of
tasks used to demonstrate its effect. For example, a brief literature search returned
tasks including (but not limited to) listening to different types of music, watching
television, using mental imagery, playing electronic games, playing board games,
number tasks, letter tasks and writing tasks – a mixture of visual and auditory tasks,
all of which draw on different neural processes, brain areas and place a variety of
demands on working memory. The wider issues surrounding distraction as a cognitive
strategy for reducing cravings are discussed in more detail in chapter five.
Mental Imagery
Based on the EI theory of desire by Kavanagh et al (2005), the use of mental imagery
interventions for smoking cessation are proposed to work via the disruption of craving
related thoughts and images, and therefore interrupt emotional and motivational cues
to smoke. Several studies have implemented guided imagery as a smoking cessation
intervention with differing degrees of efficacy; Wynd (1992a, 1992b) found that
compared with a counselling only control group, participants instructed in self-
actualisation focused ‘power’ imagery and relaxation imagery produced significantly
higher abstinence and reduced smoking rates at 6 and 12 weeks post intervention, and
a later study using guided health imagery also led to significantly higher abstinence
compared with controls up to 24-weeks post intervention (Wynd, 2005). Tindle,
Barbeau, Davis, Eisenberg, Park, Phillips and Rigotti (2006) found a non-significant
increase in abstinence and smoking rates for participants given a self-help manual,
cessation counselling and a guided imagery programme on CD compared with just
self-help and counselling, although a larger sample size may have yielded significant
results. Furthermore, in a laboratory based setting using temporarily abstinent
33
participants, Versland and Rosenberg (2007) found that participants asked to listen to
olfactory, visual or olfactory plus visual beach guided imagery instructions showed
significantly lower cravings compared with participants who completed a cognitive
distraction task (serial 7s). The results of these studies suggests that guided imagery
may be a practical, easy, safe and cost effective strategy for reducing cravings and
relapse, and would benefit from the support of more high quality RCTs.
Mindfulness
Unlike distraction or thought suppression techniques, with its origins in Buddhist
meditation, the idea of mindfulness is to accept thoughts, feelings and sensations as
they occur without making judgements or imposing meaning (Kabat-Zinn, 2003).
Developed in the late 1970s, the original Mindfulness Based Stress Reduction
(MBSR) programme was as a training vehicle for use in an outpatient stress reduction
clinic, and involved increasing awareness by providing a set of mental processing
skills to help deal with emotional distress and maladaptive behaviour (Baer, 2003). It
has since been used in many different therapeutic areas, with encouraging results in
the treatment of substance abuse and addiction (Zgierska, Rabago, Chawla, Kushner,
Koehler & Marlatt, 2009).
In terms of the use of mindfulness as an aid to smoking cessation, several studies have
used either the full or a modified version of the 8-week MBRS programme to help
smokers to quit (e.g. Davis, Fleming, Bonus & Baker, 2007; Davis, Goldberg,
Anderson, Manley, Smith & Baker, 2014a; Michalsen, Richarz, Reichardt, Spahn,
Konietzko & Dobos, 2002), whereas other have focused on the acceptance element of
mindfulness to deliver a form of Acceptance and Commitment Therapy (ACT; e.g.
34
Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki & Rasmussen-Hall, 2004; Gifford,
Kohlenberg, Hayes, Pierson, Piasecki, Antonuccio & Palm, 2011). Individual
components of mindfulness training have also been used in a laboratory setting to
examine their efficacy in reducing cigarette cravings and tobacco withdrawal
symptom; for example Bowen and Marlatt (2009), and Rogojanski, Vettese and
Antony (2011) examined a mindfulness technique they termed “urge surfing”,
whereby smokers use acceptance to “ride” the urge to smoke through its fluctuations,
and Cropley, Ussher and Charitou (2007) and Ussher, Cropley, Playle, Mohidin and
West (2009) explored the use of a guided body scan, a practice of focusing on the
breath whilst scanning different body areas, which is thought to promote relaxation.
The theoretical underpinnings of mindfulness and its associated techniques in relation
to smoking and tobacco addiction are discussed fully in chapter two, with a systematic
review and meta-analysis of their efficacy detailed in chapter three.
1.7 Aims & Objectives of research
This thesis will focus on one component of traditional mindfulness training: the
guided body scan. The act of performing a guided body scan involves utilising some
of the beneficial cognitive elements from guided imagery, mindful awareness and
may potentially serve as a distraction from cravings related thoughts. As a result, the
aim of this research is two-fold:
1. Following on from studies by Cropley et al (2007) and Ussher et al (2009)
who found that listening to a 10 minute body scan significantly reduced desire
to smoke and tobacco withdrawal symptoms, the first part of the thesis will
concentrate on the potential synergy of the body scan with NRT in producing
35
a greater reduction in cravings and withdrawal symptoms in temporarily
abstinence smokers when combined, compared to alone.
2. The mechanisms underlying the efficacy of the guided body scan are still to be
fully elucidated, so the second part of the thesis proposes and explores
“distraction” as a potential factor in the reduction of cravings and withdrawal
symptoms, and compares the effect of the body scan to other distraction
techniques.
36
CHAPTER 2
MINDFULNESS: ORIGIN, DEFINITIONS & UNDERLYING MECHANISMS
IN RELATION TO SMOKING INTERVENTIONS
2.1 Origin and definitions
As briefly discussed in chapter one, the origin of ‘mindfulness’ comes from Buddhist
texts that have been translated into English from the Pali-term ‘sati’, and is said to
mean to remember or memory (Gethin, 2011). Through the process of westernisation
however, focus has shifted primarily onto the concept of attention and awareness,
with it’s gradual incorporation into mainstream clinical practice prompting the need
for a working operational definition that led Kabat-Zinn (2003) to describe
mindfulness as:
“The awareness that emerges through paying attention on purpose, in the
present moment, and nonjudgmentally to the unfolding of experience moment
by moment” (p. 145).
In a summary of the central facets of mindfulness practice, Grossman, Niemann,
Schmidt and Walach (2004) explain how it is characterised as both non-evaluative
and non-deliberative; it involves sustained attention to on-going mental events
without thinking about, comparing or evaluating any phenomena that arise in any way
during periods of practice. It can be thought of as a form of naturalistic observation
where the “objects of observation are the perceptible mental phenomena that normally
37
arise during waking consciousness” (p. 36). The authors argue that underlying this
concept are the following assumptions: (1) people are mostly unaware of their own
momentary experiences, and tend to operate in ‘automatic pilot’ mode; (2) it is
possible to develop the ability to sustain attention to mental content; (3) developing
this ability takes time and requires regular practice; (4) on-going momentary
awareness cultivates a richer sense of self, as life experiences become more vivid and
active mindful participation replaces sub-conscious reactivity; (5) the resulting
persistent, non-evaluative observation represents a more truthful perception of reality;
and (6) more accurate perceptions of one’s mental responses to both internal and
external stimuli leads to the availability of additional information to enhance effective
actions and a greater sense of control in the world.
In line with this, Kabat-Zinn (2003) discusses how mindfulness in itself is not a belief,
ideology or philosophy, but a way of providing a coherent phenomenological
framework for thinking about the nature of the mind, emotions and relief from
suffering through the cultivation of mindful awareness. Mindfulness practice involves
not only formal meditation through the sustained focusing of attention on the body,
breath and sensations, but also informal non-meditation based practices in the
application of mindful awareness to everyday life (Hick, 2010). For the purposes of
empirical study, Bishop et al (2004) further separate the Western version of
mindfulness into two distinct components; the self-regulation of attention to an
individual’s immediate experience, and the adoption of an open, non-judgmental, and
acceptance orientated view of the present moment. In this respect, mindful awareness
can be seen as standing in contrast to both emotional avoidance and emotional over-
engagement (Hayes & Feldman, 2004).
38
Mindfulness practice has been used clinically to reduce the symptoms associated with
a variety of physical and psychological issues such as chronic pain, eating disorders,
stress, anxiety and depression (e.g. Morone, Greco & Weiner, 2008; Baer, Fischer &
Huss, 2005; Rosenzweig, Reibel, Greeson & Edman, 2007; Hofmann, Sawyer, Witt &
Oh, 2010), with researchers more recently exploring their use in the treatment of a
variety of substance use disorders (e.g. Silpakit, 2015; Dakwar & Levin, 2013;
Witkiewitz & Bowen, 2010; Brewer et al, 2009). Due to the myriad facets of
mindfulness in therapeutic practice, mindfulness-based interventions for smokers
have taken many different forms. The next section offers an introduction to the ways
in which mindfulness has been used to help smokers both quit and manage cravings
during periods of temporary abstinence, and chapter three presents a full systematic
review of the different types of mindfulness based smoking intervention and their
efficacy.
2.2 Mindfulness interventions for smokers
2.2.1 Mindfulness Based Stress Reduction (MBSR)
The first clinical application of mindfulness was developed by John Kabat-Zinn in
1979, and took the form of an 8-week ‘Mindfulness Based Stress Reduction’ course
for people attending an outpatient chronic pain and stress reduction clinic. It consisted
of weekly workshops with certified trainers, therapist-led group sessions, a full-day
retreat and daily home practice. It involved instruction in sitting meditation, a body
scan (see section 2.2.4), and hatha yoga postures (Grossman, Niemann, Schmidt &
Walach, 2004). The idea was to provide patients with strategies to face, explore and
39
relieve suffering, as well as to complement medical treatment in patients who were
failing to respond well to conventional therapy.
Altner (2002) and Michalsen, Richarz, Reichardt, Spahn, Konietzko and Dobos
(2002) were the first studies to investigate the feasibility of using the traditional 8-
week MBSR course, which was combined with NRT in both cases, to help smokers
quit. The results of these studies produced mixed results, with participants in the
mindfulness group reporting significantly higher rates of abstinence up to 6-month
post-quit in the Altner (2002) study, but no significant difference in abstinence rates at
any time point post-quit in the Michalsen et al (2002) study. The quality of the
research, and reporting of methodology and results in both studies were however
lacking in detail (see chapter three for full systematic review), particularly in relation
to abstinence validation. Furthermore, both studies also allowed participants to choose
which ‘intervention’ group they wanted to be part of, thereby removing randomisation
and blinding, and introducing the possibility of selection bias.
Later studies using modified versions of MBSR training for smoking cessation tended
to utilise more rigorous research practices. Brewer, Mallik, Babuscio, Nich, Johnson,
Deleone, Minnix-Cotton, Byrne, Kober, Weinstein, Carroll and Rounsaville (2011)
employed ‘mindfulness training’ and Davis, Goldberg, Anderson, Manley, Smith and
Baker (2014a), and Davis, Manley, Goldberg, Smith and Jorenby (2014b) used
mindfulness training specifically tailored in content for smoking cessation by
including additional instruction on the mindful management of smoking triggers,
urges, addictive thoughts and emotions. The results of the studies by Brewer et al
(2011) and Davis et al (2014a) report significantly higher abstinence rates in the
mindfulness groups compared to controls at 17 week and 24 weeks respectively as
40
well as significant improvement in emotion regulation, attention control and
mindfulness in the intervention groups. And while there were no significant
differences in abstinence to report at 24-weeks post-quit in the Davis et al (2014b)
study, participants showed a significant decrease in ratings of urge to smoke, self-
reported stress and experiential avoidance in the mindfulness group compared with
controls. One issue reported in the studies was low compliance with home practice
outside of group sessions, and this is particularly problematic in light of findings by
Davis, Fleming, Bonus and Baker (2007) that time spent doing mindfulness
meditation was a significant predictor of smoking abstinence in a one-armed pilot
study examining the effect of MBSR on smokers.
2.2.2 Acceptance and Commitment Therapy (ACT)
Based within the realms of contemporary behavioural therapy, Hayes, Strosahl &
Wilson (1999) developed ACT to combine traditional mindfulness and acceptance
with a commitment to behaviour change. The aim of the therapy is to increase levels
of self-control through the development of skills in accepting and re-contextualising
internal experiences so that individuals are able to respond differently to negative
affect, reduce avoidance and increase both cognitive and behavioural flexibility
(Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki, Rasmussen-Hall & Palm, 2004).
Patients are encouraged to make overt behavioural choices based on goals that reflect
their life values, and rather than seeking to change the content of thoughts and
feelings, they are encouraged to change their attitude towards those thoughts and
feelings (Zgierska, Rabago, Chawla, Kushner, Koehler & Marlatt, 2009).
41
Gifford and colleagues (Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki,
Rasmussen-Hall & Palm, 2004; Gifford, Kohlenberg, Hayes, Pierson, Piasecki,
Antonuccio & Palm, 2011) conducted two studies using ACT as a smoking cessation
intervention. The Gifford et al (2004) study compared a group of smokers
participating in a 7-week ACT programme with a control group who only received
NRT, and the Gifford et al (2011) study compared smokers enrolled on a 10-week
ACT programme plus bupropion, with a control group who only received bupropion.
Both studies showed significantly higher abstinence in the intervention arm compared
with controls at the 1-year follow-up point, although there were no significant
differences in ratings of withdrawal symptoms or negative affect between the groups
in the 2004 study. The 2011 study did however find that the acceptance of, rather than
reaction to, internal smoking cues such as physiological withdrawal symptoms was a
significant mediator of abstinence, and this supports the theory that the acceptance of
internal experiences can help change habitual responses to negative states. This
suggests that the ACT programme may have helped smokers to adjust their thoughts
regarding cravings and withdrawal, and in turn modify their behavioural response.
2.2.3 Urge surfing
The urge surfing technique was developed by Marlatt and Gordon (1985) as part of
the clinical application of Mindfulness Based Relapse Prevention (MBRP: Bowen,
Chawla, Collins, Witkiewitz, Hsu, Grow, Clifasefi, Garner, Douglass, Larimer &
Marlatt, 2009), and is often included as part of a larger relapse prevention
programme. According to Bowen and Marlatt (2009), the intensity of an urge tends to
fluctuate over a relatively short period of time usually before disappearing, and the
urge surfing technique can be thought of as “riding” the urge to consume a substance
42
or engage in an unwanted behaviour. They suggest that individuals use visual imagery
to picture their urges as waves, and imagine riding the waves through the natural ebbs
and flows, rather than fighting against or surrendering to them. They argue that the
practice of observing negative affect and urges without responding to them helps
individuals learn an adaptive response to adverse experiences.
The use of urge surfing as a smoking intervention has focused on the acute effects it
may have on the management of cravings and negative affect rather than as cessation
aid per say. Bowen and Marlatt (2009) conducted the first study on urge surfing using
audio recordings of smoking cue exposure plus the urge surfing technique combined
with the acceptance and non-judgment elements of mindfulness training. The control
condition was instructed simply to use any coping strategy they would normally draw
upon to manage smoking urges. No significant effect on urges or negative affect was
found for either group, however there was a significant reduction in smoking rates in
the mindfulness group, but not controls, at the 7-day follow-up point. A later study by
Rogojanski, Vettese and Antony (2011) used an audio recording of smoking cue
exposure plus urge surfing and acceptance and non-judgement, and compared it to a
control group who listened to cue exposure plus thought suppression instructions.
Unlike Bowen and Marlatt (2009), they found that negative affect, depression and
nicotine dependence were all significantly reduced at the 7-day follow-up point for
the intervention group compared to controls, but that there were no significant
difference in post-audio cravings or day 7 smoking rates between the two groups.
It is difficult to draw any firm conclusions from these brief laboratory based urge
surfing interventions, as the results completely contradict each other. A recent pilot
43
study by Ruscio, Muench, Brede and Waters (2016) did however compared the effects
of 2 weeks of daily mindfulness practice (including urge surfing, and mindfulness of
the breath, body, thoughts and emotions) with sham meditation (including to manage
cravings using their normal technique, mind wandering or to judge their experiences),
on self-reported affect, cravings and smoking rates. They found that both negative
affect and cravings were significantly reduced immediately post-audio for the
mindfulness group compared to controls, as were the number of cigarettes smoked per
day. Whilst it may be difficult to isolate the effects of the urge surfing from the other
mindfulness techniques followed by the participants, this suggests that urge surfing
may be a useful tool in managing cravings and regulating mood, however daily
practice may be necessary to bring about any true benefits.
2.2.4 The body scan
The body scan technique is a somatically orientated, attention focusing practice that
was first used as part of Kabat-Zinn’s MBSR programme (Dreeben, Mamberg &
Salmon, 2013). The practice involves sitting or lying down in a comfortable position,
whilst an instructor (live or on a pre-recorded format) slowly guides the participant’s
attention through different areas of the body using the breath as a focus. Kabat-Zinn
(1990) likens the body scan process to a sweeping ‘zone-purification’ of the body that
helps to stabilise attention and anchor the mind’s focus. Once attention is focused, the
mind is free to notice how transient and fleeting experiences are, and how naturally
the mind tends to automatically judge each momentary sensation. The goal of the
body scan is to become aware of and acknowledge bodily sensations whilst learning it
is not necessary to judge or react to them. Dreeben et al (2013) argue that this is a
form of cognitive dis-identification that enables the participant to separate their
44
moment-to-moment experiences from any preconceived ideas and opinions, thus
cultivating mental flexibility and helping to retain a sense of perspective.
The first study to look at the body scan in relation to smoking was by Ussher, West,
Doshi and Sampuran (2006), although the body scan was not the main focus of the
research, and instead formed the control arm of the study. The research was designed
to examine the acute effects of isometric exercise on desire to smoke and tobacco
withdrawal symptoms, and compared with the exercise conditions the body scan did
not have any significant impact on ratings. However Cropley, Ussher and Charitou
(2007) recognised the potential utility of the body scan as a therapeutic intervention
and criticised the procedures used by Ussher et al (2006) for failing to adequately
guide participants through the body scan routine. As a result, they designed an
investigation to explore the acute effects of a guided body scan versus a neutral audio
recording, on ratings of desire to smoke and withdrawal symptoms. Temporarily
abstinent participants listened to a 10-minute audio recording of the guided body scan
routine or a passage from a natural history text (considered to be neutral but relaxing)
and rated their urge to smoke and withdrawal symptoms up to 15-minutes post-
intervention. The results indicated that there was a significant group by time
interaction, with significantly lower ratings given for irritability, tension and
restlessness by the body scan group relative to control group. Furthermore, the
‘strength of desire to smoke’ ratings were significantly lower in the body scan
condition up to 5-minutes post intervention compared to the control. The authors
propose that the body scan acts as an effective stress reduction technique, and that
guiding participants through the routine via an audio recording is a more effective
technique than placing limited instructions on cards.
45
A later study by Ussher, Cropley, Playle, Mohidin and West (2009) built on the work
of Cropley et al (2007) and sought to examine the effects of the guided body scan and
isometric exercise on cigarette cravings and withdrawal symptoms. Temporarily
abstinent smokers listened to a 10-minute audio delivered guided body scan, an
isometric exercise routine or a passage from a natural history text, but this time
participants used the intervention both in the laboratory and again in their natural
environment at a time they felt a strong desire to smoke. The results showed that
ratings of desire to smoke were significantly lower in body scan and isometric
exercise groups compared to the control group up to 30-minutes post-intervention in
the lab setting, and up to 5-minutes post-intervention in the natural environment
setting. Irritability, difficulty concentrating and stress were also reduced in the body
scan group compared with controls in the laboratory setting, and irritability, difficulty
concentrating and restlessness were also reduced in the body scan group compared
with controls in participants’ natural environment. The authors do not offer any
suggestions regarding the possible underlying mechanisms responsible for the
observed effects, however both studies provide positive evidence of the potential
efficacy of using a brief body scan intervention in the management of acute cigarette
cravings and withdrawal.
To summarise, while the effectiveness of mindfulness-based interventions has been
evaluated and supported in a number of studies, there is still a lack of consensus
regarding it’s impact on constructs such as negative affect and the psychological
processes responsible for negating cigarette cravings and tobacco withdrawal. The
following section seeks to explore some of the theories surrounding the potential
46
underlying mechanisms in more detail.
2.3 Mindfulness mechanisms
2.3.1 Cognitive flexibility and attention control
As discussed in chapter one, once an addiction to tobacco is established, the habitual
act of smoking can occur with very little conscious effort. The act of resisting a
craving episode however requires significant attention and cognitive effort due to the
non-automatic cognitive processes that occur in response to the voluntary or
involuntary obstacle blocking the automatised smoking behaviour (Tiffany, 1999).
Kavanagh, Andrade and May’s (2005) elaborated intrusion (EI) theory of desire argue
that while the urge to smoke may arise from a spontaneous intrusive thought, intrusive
thought will only emerge fully into consciousness and be acted upon if elaboration
occurs via actively controlled cognitive processing. They claim that the likelihood of
elaboration occurring depends on how strongly the smoker identifies with their
rumination of smoking related thoughts and images, and the subsequent level of
attention directed to target relevant stimuli.
In light of this, a study by May, Andrade, Willoughby and Brown (2012) examined
the effect of a 10-minute guided body scan versus mind wandering instructions on
smokers’ frequency of smoking related thoughts and craving levels. They report that
there were significantly fewer smoking related thoughts and cravings following the
body scan compared to the mind wandering, and that the body scan may have reduced
cravings by either reducing the frequency or shortening the duration of smoking
related thoughts. A central tenet of mindfulness however, is the present moment
47
acceptance of thoughts without judgment (no matter how unpleasant), and to decrease
avoidance and suppression. By this argument, the frequency and duration of smoking
related thoughts should be irrelevant. In line with this, a study by Bowen, Witkiewitz,
Dillworth and Marlatt (2007) showed how individuals suffering from alcohol
addiction who took part in a 10-day mindfulness meditation (Vipassana) course
reported a greater decrease in attempts to avoid unwanted thoughts compared with
controls that did not take part in the course. Furthermore, the changes in levels of
avoidance mediated the relationship between mindfulness practice and alcohol use in
the subsequent three months, despite participants failing to report any significant
decrease in unwanted thoughts. This supports the theory that mindfulness does not
necessarily decrease the frequency of, or attention paid to smoking related thoughts,
but may instead alter the way in which individuals process them. According to
Breslin, Zack and McMain (2002), this represents a shift in perspective from ‘actor’
to ‘observer’, and may reduce the inherent urgency of a craving episode by
attenuating the subjective ‘pull’ exerted by the eliciting stimuli, thereby reducing the
likelihood of substance use.
This concept of mindful attention promoting cognitive flexibility fits well with the
mindfulness-based relapse prevention (MBRP) programme developed by Witkiewitz,
Marlatt and Walker (2005). The course consisted of promoting awareness and
acceptance of the psychological and physiological reactions to the experience of
craving and substance withdrawal, as well as how to identify high-risk situations. The
authors argued that this heightened awareness resulted in the cultivation of more
adaptive strategies for responding to situational cues, thereby reducing the risk of
relapse. Consequently, repeated experiences of successfully overcoming a craving
48
episode in a high-risk situation whilst employing mindfulness skills should eventually
lead to increased self-efficacy and re-conditioning of existing positive and negative
reinforcement associated with the abused substance. A study by Moore and
Malinowski (2009) also supports the association between mindfulness practice and
the development of cognitive flexibility and attention control. They compared the
performance of mindfulness meditation practitioners with meditation-naïve controls
on a Stroop (1992) interference task and d2-concentration and endurance test (d2-test;
Brickenkamp & Zilmer, 1998). Their results showed that both attentional performance
and cognitive flexibility were positively associated with levels of mindfulness.
Furthermore, the decreased interference on the Stroop test by mindfulness
practitioners suggests that previously automatised cognitive processes (e.g. cravings)
can be brought back under cognitive control, and the previously automatic response
(e.g. smoking) can be successfully interrupted (Diekman, 2000).
A further study by Chambers, Lo and Allen (2008) examined at the role mindfulness
plays in attention control, and suggest that mindfulness practice aids the cultivation of
two aspects of executive functioning; sustained attention (the ability to focus
attentional resources on specific stimuli, e.g. the breath), and attention switching (the
ability to switch attentional focus between stimuli). The authors argue that the present
moment awareness associated with mindfulness has the capacity to improve both
facets of attention as well as the inhibition of elaborative processing (Bishop et al,
2004). This in turn increases the potential for self-regulation by allowing the focus of
attention to be redirected away from ruminative thoughts and brought back to the
present moment (Shapiro & Schwarz, 2000). Participants in Chambers et al (2008)
study consisted of 20 individuals who took part in a 10-day intensive Vipassana
49
course versus 20 wait-list controls, with the results indicating significant
improvements in self-reported mindfulness, depression, rumination, measures of
working memory and sustained attention in the mindfulness group compared to
controls. In terms of using mindfulness practice to manage tobacco related cravings
and withdrawal, this supports the idea that via improvements in cognitive processes
such as sustained attention; mindfulness enhances the ability to monitor and self-
regulate internal mental states and may reduce reactivity to smoking urges.
A number of neurological studies have also found evidence to suggest that
mindfulness training has the potential to enhance attentional stability. For example, a
functional magnetic resonance imaging (fMRI) study by Brefczynski-
Lewis, Lutz, Schaefer, Levinson and Davidson (2007) explored the neural correlates
of attentional expertise in long-term mindfulness meditators compared with novice
meditators. Participants alternated between focusing on a small fixation dot on a
screen (meditative state) and being in a resting state, and were probed by being
presented with positive, negative and neutral sound based distracting external stimuli.
The results indicated that compared with novice meditators, experienced meditators
showed greater activation in areas of the brain associated with attentional control
(frontoparietal, cerebellar, temporal and parahippocampal regions), whereas novice
meditators showed more activation in the medial frontal gyrus and anterior cingulate
regions of the brain that correlate negatively with performance on sustained attention
tasks. Interestingly, they then split the experienced meditators into the most and least
hours of practice and found that those with the most hours of practice had less
activation in brain areas related to discursive thoughts and
emotions, and more activation in areas related to response
50
inhibition and attention. This suggests that greater practice leads to
reductions in resource allocation without any compromise in
performance (i.e. more efficient processing) and may indicate
neural plasticity in brain areas linked to attentional processing
mechanisms.
A study by Lutz, Slagter, Rawlings, Francis, Greischar and Davidson (2009) also
supports the idea that the ability to sustain attention and its associated brain circuitry
are transformable through training. Using a dichotic listening task and measuring
brain output via electroencephalography (EEG), they found that following three
months of intensive mindfulness meditation training, participants showed reduced
variability in attentional processing of target tones. Furthermore, the EEG results
show that focused attention meditation (such as a guided body scan) can affect both
distractor and target processing by “enhancing entrainment of neuronal oscillations to
sensory input rhythms” (p. 13,418), which is an important mechanism for controlling
the content of attention. These findings again highlight the potential brain
mechanisms underlying the mindfulness practice of focused attention, and support the
idea that training has the ability to significantly improve attentional control.
To summarise, it is this flexibility of awareness and control of attention during a
craving episode that mindfulness training is thought to have a positive impact upon.
Mindfulness-based attentional control strategies may help manage cravings by
helping smokers to be aware of the thoughts and sensations normally associated with
the urge to smoke without necessarily judging or reacting to them. This occurs via the
cultivation of flexibility in the application of attention to both smoking cues and
51
thoughts, and the impulse to react to these cues may create a ‘mental gap’ that enables
an adaptive (rather than habitual) response to occur (Brown, Ryan & Creswell, 2007).
2.3.2 Affect/emotion regulation
Anecdotally, virtually all smokers attribute their smoking behaviour, at least in part,
to it’s ability to relieve negative affect (Frith, 1971). They also reliably claim to
smoke more when stressed or anxious (Shiffman, 1993), and argue that smoking
successfully alleviates these negative mood states (Brandon & Baker, 1991). In terms
of tobacco abstinence, there are strong links between high levels of negative affect,
the urge to smoke and smoking lapses (e.g. Niaura, Shadel, Britt & Abrams, 2002;
Tiffany & Drobes, 1991; Shiffman & Waters, 2004), and nicotine withdrawal is
known to result in various forms of affective disruptions including anxiety, irritability
or depression, as well as physical and cognitive symptoms such as difficulty
concentrating and restlessness (Shiffman & Jarvik, 1976). Emotion regulation is
defined as the process of consciously or unconsciously modulating one or more
aspects of an emotional experience or response, and is essential for psychological
well-being (Gross, 1998). Furthermore, interventions to enhance emotion regulation
have been shown to be effective in reducing a variety of deleterious psychological
symptoms (Nyklíček, 2011). With negative affect purportedly having such a powerful
influence on smoking behaviour, it is clear to see why emotion regulation has been
proposed as the underlying mechanism responsible for the salutary effects seen in
mindfulness interventions. This section will now explore some of the research that has
looked at both the effect of brief mindfulness interventions and dispositional levels of
‘trait’ mindfulness, as measured by the Mindfulness Attention Awareness Scale
52
(MAAS; Brown & Ryan, 2003), and their effect on various aspects of emotion
processing.
A study by Arch and Craske (2006) examined the moderating role of a brief
mindfulness task on responses to laboratory induced stressors by examining emotion
regulation following a 15-minute focused breathing exercise (mindfulness) compared
with unfocused attention (mind wandering) or worrying. Participants viewed a series
of positive, negative and neutral picture slides from the International Affective Picture
System (IAPS; Lang, Bradley & Cuthbery, 1999) before and after the interventions,
with the mindfulness group maintaining a consistent, moderately positive response to
the neutral slides both before and after induction, whereas the control groups both
responded significantly more negatively after the induction compared to before. The
mindfulness group also reported lower negative affect and overall emotional volatility
in response to the post-intervention slides, and a greater willingness to view a series
of optional negative slides relative to both control groups. This is also in line
with the previously discussed results of the urge surfing intervention
used during smoking cue exposure by Rogojanski, Vettese and Antony
(2011), who report that negative affect, depression and nicotine dependence were all
significantly reduced in the intervention group compared with the thought suppression
control group. The findings from both of these studies indicate that brief mindfulness
interventions can result in improved emotion regulation in response to (laboratory
induced) negative affect, and support the idea that mindfulness based exercises may
be useful smoking cessation aids due to their ability to counteract negative affect
experienced during cigarette craving episodes.
53
In contrast to these findings however, a similar laboratory based smoking cue
exposure study by Bowen & Marlatt (2009) found no change in levels of self-reported
negative affect or smoking urges following their urge surfing intervention, despite a
significant reduction in smoking rates between baseline and day 7 follow-up in the
mindfulness group compared with controls. It is possible however, that rather than
reducing levels of negative affect per se, mindfulness training instead modified how
participants responded to the adverse experiences of cravings and withdrawal
symptoms. In other words, through the practice of observing negative affect/urges
without reacting to them, they learnt an alternative response to the adverse experience
and resisted the impulse to smoke. Volatility to negative affect has been shown to be
a critical determinant of smoking relapse (e.g. Cofta-Woerpel, McClure, Li, Urbauer,
Cinciripini & Wetter, 2011), and the idea that mindfulness promotes reduced
reactivity to emotionally challenging situations is supported by Adams, Chen, Guo,
Lam, Stewart, Correa-Fernández, Cano, Heppner, Vidrine, Li, Ahluwalia, Cinciripini
and Wetter (2014), who conducted a longitudinal study looking at associations
between dispositional mindfulness, as measured by the MAAS (Borwn & Ryan,
2003), and emotional responses throughout the course of smoking cessation treatment.
They found that trait mindfulness was a significant predictor of lower affective
volatility, and suggest that mindfulness is linked to greater stability of general affect,
which in turn has a positive impact on the chances of successfully quitting.
From a neurological perspective, this is further supported by Creswell, Way,
Eisenberger and Lieberman (2007), who used fMRI scanning while participants
viewed emotionally negative pictures. They contend that based on both historical and
contemporary accounts of mindfulness practice, skilful labelling of emotional
54
experiences cultivates better recognition of, detachment from and regulation of
affective experiences. Their results indicated that people who scored higher on the
MAAS (Brown & Ryan, 2003) were less reactive to threatening emotional stimuli, as
indicted by reduced bilateral amygdala response and greater prefrontal cortical
activation during the labelling of emotive stimuli. They argue that greater mindfulness
ability results in better affect regulation via the enhanced prefrontal cortical inhibition
of amygdala response, and suggest that it may reduce negative affect via
an improved ability to label negative or threatening feelings.
According to Chiesa, Serretti and Jakobsen (2013), current neurobiological evidence
points to the existence of two distinct emotion regulating strategies. The first is
cognitive reappraisal, which manipulates the input received by the emotion-generative
system by reinterpreting emotional stimuli to reduce it’s impact (Gross, 1998), and
involves a ‘top-down’ regulation of the prefrontal cortex on emotion generative
regions of the brain such as the amygdala (e.g. Quirk & Beer, 2006). The second
strategy involves the modulation of emotion-generative brain regions without
cognitive reappraisal, and involves ‘bottom-up’ regulation via the “direct reduced
reactivity of “lower” emotion-generative brain regions without an active recruitment
of “higher” brain regions, such as the pre-frontal cortex” (p. 83) (e.g. van den Hurk,
Janssen, Giommi, Barendregt & Gielen, 2010). The study by Creswell et al (2007)
clearly supports the ‘top-down’ theory of emotion regulation in that greater trait
mindfulness was linked to reduced bilateral amygdala response and greater prefrontal
cortical activation during emotional processing, however a study by Westbrook,
Creswell, Tabibnia, Julson, Kober and Tindle (2013) looking at a brief mindfulness
intervention and cue induced cravings in smokers supports a ‘bottom-up’ approach.
55
Westbrook et al (2013) asked participants to view three types of pictures (smoking,
neutral and aversive) and to mindfully attend to the images, or relax and look at them
as naturally as possible. More specifically, the mindful attention instructions asked
participants to actively focus on their responses to the pictures in terms of thoughts,
feelings, bodily sensations and memories whilst maintaining a non-judgmental
attitude towards those responses. The results found that participants reported
significantly higher cravings and distress when asked to ‘relax and look’ at the
smoking images compared to ‘mindfully attending’ to them. Furthermore, the authors
observed a decrease in neural activity in a craving-related region of the subgenual
anterior cingulate cortex as a result of the mindful attention, but there was no
significant difference in the activity of the prefrontal cortex between the mindful-
smoking versus the look-smoking conditions. The findings from these two studies
provide support for the existence of both ‘top-down’ and ‘bottom-up’ emotion
regulation strategies, and it is quite plausible that mindfulness interventions affect
both emotional processing systems.
To summarise, the cultivation of unprejudiced receptivity through mindfulness
practice – particularly in the promotion of self-control during emotionally challenging
situations – leads to increased tolerance in the face of unpleasant emotional stimuli
without resorting to cognitive reactivity. This means that in terms of it’s salutary
effect on cigarette cravings and withdrawal symptoms, mindfulness practice may
reduce emotional volatility to smoking related cues during high-risk situations and
consequently counteract the impulsive behaviour that would normally lead to smoking
relapse. Furthermore, neuroimaging evidence suggests that there are a number of
56
ways in which mindfulness practice modifies and enhances the neural mechanisms
associated with both attentional and affective control of impulsive behaviours, with
cognitive flexibility and reduced reactivity being key features in the models
associated with both. Following on from this discussion of potential mindfulness
mechanisms, the next chapter presents a systematic review with meta-analysis of the
efficacy of current mindfulness based interventions for both acute tobacco cravings
and long-term smoking cessation.
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CHAPTER 3
MINFULNESS TECHNIQUES FOR SMOKING CESSATION: A
SYSTEMATIC LITERATURE REVIEW WITH META-ANALYSIS
3.1 Introduction
Aided quit attempts through a combination of cognitive-behavioural support and
nicotine replacement therapy (NRT), bupropion or varenicline, can improve smoking
cessation success rates by around 50 – 80% (Stead, Perera, Bullen, Mant, Hartmann-
Boyce, Cahill & Lancaster, 2012; Hughes, Stead, Hartmann-Boyce, Cahill &
Lancaster, 2014; Cahill, Stevens, Perera & Lancaster, 2013). Whilst the
pharmaceutical approach to smoking cessation helps manage the biochemical
dependence on tobacco (Dewey, Brodie, Gerasimov, Horan, Gardner & Ashby, 1999),
the technique of mindfulness has been proposed as a strategy for providing relief from
the behaviourally reinforcing effects of nicotine that sustain psychological
dependence on tobacco (e.g. Breslin, Zack & McMain, 2002; Baer, 2003; Vidrine,
Businelle, Cinciripini, Li, Marcus, Waters, Reitzel & Wetter, 2009).
Nicotine dependence is a central factor in maintaining tobacco addiction and high
dependence a significant predictor of withdrawal severity and consequent relapse
58
(Kozlowski, Porter, Orleans, Pope, & Heatherton, 1994; Stapleton, Russell,
Feyerabend, Wiseman, Gustavsson, Sawe & Wiseman, 1995). Nicotine can provide
both positive reinforcement (e.g. smoking improves mood, enhances concentration or
dampens appetite) and negative reinforcement (e.g. smoking relieves withdrawal
symptoms, stress or anxiety), and this operant conditioning forms associative
memories which when triggered by an external or internal cue, lead to cue-induced
cravings and subsequent smoking (Bevins & Palmatier, 2004). One of the key
characteristics of mindfulness is the acceptance of thoughts and feelings, and the
ability to learn to acknowledge the transient nature of these sensations and avoid
reacting impulsively to them (Bishop, Lau, Shapiro, Carlson, Anderson, Carmody,
Segal, Abbey, Speca, Velting & Devins, 2004). It is argued that the cultivation of
reduced reactivity and cognitive flexibility helps smokers resist the urge to smoke
during a craving episode (Greeson, 2009), thereby disrupting the established link
between craving and smoking behaviour, and eventually breaking the habit (Elwafi,
Witkiewitz, Mallik, Thornhill & Brewer, 2013).
Mindfulness training has also been found to lead to neural changes in the anterior
cortical region associated with reductions in anxiety and negative affect, and
increased positive affect (Davidson, Kabat-Zinn, Schumacher, Rosenkranz, Muller,
Santorelli, Urbanowski, Harrington, Bonus & Sheridan, 2003; Jain, Shapiro, Swanick,
Roesch, Mills, Bell & Schwartz, 2007; Chambers, Lo & Allen, 2008). It has also been
linked to the recruitment of ‘regulatory’ neural pathways underlying the control of
emotions (Westbrook, Creswell, Tabibnia, Julson, Kober & Tindle, 2013). This
‘active regulation’ is consistent with better management of negative emotions, such as
those related to withdrawal symptoms (Ivanovski & Malhi, 2007), and supports the
59
theory that mindfulness reduces nicotine dependence through its ability to attenuate
negative mood. With this growing body of research examining the benefits of
mindfulness in the treatment of tobacco addiction, the aim of this review is to
establish the efficacy of mindfulness-based therapies as an aid to craving reduction
and smoking cessation.
3.2 Objectives
The main objective of this review is to evaluate the effectiveness of smoking
interventions that utilise mindfulness based techniques for reducing cravings and
aiding cessation. A preliminary review of the literature suggested that the studies
naturally fell into those conducted in a laboratory (categorised as acute) and those
conducted as part of a cessation programme, with the analysis and results reflecting
this division.
3.3 Criteria for inclusion
The inclusion criteria were determined by the SPIO (Study Design, Participants,
Intervention, Outcome) framework, which has been commonly used to define the
perimeters of systematic reviews in cases where designs other then RCTs are included
for analysis (Joanna Briggs Institute, 2011).
3.3.1 Study design
Wide literature searches were performed, and due to the limited number of studies on
the topic, all research was included irrespective of design. This included randomised
controlled trials (RCTs), prospective cohort studies, pilot studies and unpublished
dissertations.
60
3.3.2 Participants
Those included were smokers aged over 18 years, who were not pregnant, receiving
psychiatric treatment or suffering from any mental disabilities.
3.3.3 Interventions
Mindfulness has been developed and adapted in many different ways to suit the needs
of different cohorts, and is therefore very heterogeneous in its use as a therapeutic
intervention. For the purpose of this review, all forms of mindfulness technique were
included for consideration (e.g. mindfulness based stress reduction (MBSR),
mindfulness based cognitive therapy (MBCT), guided body scanning, mindfulness
meditation and urge surfing). Furthermore, no restrictions were made based on the
intensity, frequency or duration of any mindfulness element used wholly or in part
during an intervention.
3.3.4 Outcome measures
Primary outcome measures were restricted to smoking abstinence, smoking reduction,
and self reported levels of cigarette craving and nicotine withdrawal symptoms. Any
significant secondary outcomes were also reported. Adherence to abstinence required
biochemical verification using expired breath carbon monoxide (CO), saliva cotinine
or saliva thiocyanate levels, as self-reporting can lead to false cessation rates of up to
30% (Ruth & Neaton, 1991). Despite the heterogeneity of the mindfulness based
interventions, meta-analysis was conducted on all cessation studies reporting data for
the dichotomous outcome criteria of abstinent versus relapsed participants at the final
follow-up point.
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3.4 Search strategy for identification of studies
The following databases were searched: the Cochrane Library Database, PsychInfo,
Medline and EMBASE using the search terms smok$; smoking cessation;
intervention; mindful$; “body*scan”; abstinen$; quit$; craving$; withdrawal. The
symbol $ was used at the end of search terms to represent truncation and allow all
variations of the word to be elicited. As recommended by Glasziou, Irwig, Bain and
Colditz (2001), the search was then refined by searching for participant characteristics
(i.e. adult, human) and by outcome characteristics (i.e. cessation, astinenc$, quit$).
We also carried out a hand search of reference lists and conducted additional searches
on key authors and contacted key researchers in the field. Articles were not limited to
those written or published in English. Searches were completed in January 2016.
3.5 Data collection & synthesis
An initial search identified 4,943 abstracts (see figure 3.1), which decreased to 4,890
once duplicates were removed. One reviewer screened the remaining records via title
and abstract for eligibility, and 26 articles were retained and further screened by two
reviewers for inclusion.
One study was excluded as participants were aged under 18 years of age (Black,
Sussman, Johnson & Milam, 2012), three were excluded due to participants classified
as suffering from a mental disability (Singh, Lancioni, Myers, Karazsia, Winton &
Singh, 2014; Singh, Lancioni, Winton, Karazsia, Singh, Singh & Singh, 2013; Singh,
Lancioni, Winton, Singh, Singh & Singh, 2011), three constituted a re-analysis of data
already to be included in the review (Elwafi, et al, 2013; Goldberg, Del Re, Hoyt &
Davis, 2014; Schuman-Olivier, Hoeppner, Evins & Brewer, 2014), and despite being
62
part of a cessation trial, two studies reported no control group data, abstinence rates or
follow up (Goldberg, Davis & Hoyt, 2013; Vidrine, et al, 2009), and one failed to
report separate abstinence rates for the control and experimental conditions (Arcari,
1997).
Figure 3.1 Flow diagram of study selection and exclusion process
Sixteen articles were retained for the review, and of these studies seven were
classified as acute studies (Bowen & Marlatt, 2009; Cropley, Ussher & Charitou,
2007; May, Andrade, Willoughby & Brown, 2012; Rogojanski, Vettese & Antony,
2011; Ruscio, Muench, Brede & Waters, 2016; Ussher, Cropley, Playle, Mohidin &
West, 2009; Westbrook et al, 2013), and nine were classified as cessation studies (Al-
Chalabi, Prasad, Steed, Stenner, Aveyard, Beach & Ussher, 2008; Altner, 2002;
4,943 records identified through database searching
Title and abstract screen (n = 4,890)
Duplicate records (n = 53)
Unique articles included (n = 16)
Acute studies (n = 7)Cessation studies (n = 9)
Excluded articles (n = 10)
Non-relevant population (n = 4) Reanalysis of included studies (n = 3) Unclear outcomes (n = 3)
Full text review (n = 26)
Excluded Records (n = 4,867)
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Brewer, Mallik, Babuscio, Nich, Johnson, Deleone, Minnix-Cotton, Byrne, Kober,
Weinstein, Carroll & Rounsaville, 2011; Davis, Fleming, Bonus & Baker, 2007;
Davis, Goldberg, Anderson, Manley, Smith & Baker, 2014a; Davis, Manley,
Goldberg, Smith & Jorenby, 2014b; Gifford, Kohlenberg, Hayes, Antonuccio,
Piasecki, Rasmussen-Hall & Palm, 2004; Gifford, Kohlenberg, Hayes, Pierson,
Piasecki, Antonuccio & Palm, 2011; Michalsen, Richarz, Reichardt, Spahn,
Konietzko & Dobos, 2002).
Nine studies were undertaken in the United States (Bowen & Marlatt, 2009; Brewer et
al, 2011; Davis et al, 2007; Davis et al, 2014a; 2014b; Gifford et al, 2004; 2011;
Ruscio et al, 2016; Westbrook et al, 2013) four in the United Kingdom (Al-Chalabi et
al, 2008; Cropley, Ussher & Charitou, 2007; May et al, 2012; Ussher et al, 2009), two
in Germany (Altner, 2002; Michalsen et al, 2002), and one in Canada (Rogojanski,
Vettese & Antony, 2011). In total, 1,547 participants took part in the studies with
sample sizes ranging from 18 to 303. Three studies did not include a separate control
group (Davis et al, 2007; May et al, 2012; Westbrook et al, 2013).
For the acute studies, the following data were extracted from each research paper:
country of study, study design, recruitment, randomisation and blinding procedures;
participant characteristics (including number, gender ratio, mean age, smoking
behavior and history, and level of nicotine dependence); type and description of
intervention and control arms (including duration of testing and length of follow up
period); temporary abstinence validation; summary of main findings. In addition to
these characteristics, the following data were further extracted for the cessation
studies: number and duration of sessions; rates of adherence to, and attrition from the
64
programme; definition of cessation and method of validation. Full details of these
characteristics are tabulated in table 3.1 (acute studies) and table 3.2 (cessation
studies).
65
Table 3.1
Characteristics of acute studies
Authors/ Country of Study
Participants Abstinence required
Abstinence Validation
Type of Intervention
Experimental Conditions
Control Conditions
Follow up Attrition Main Findings
Bowen & Marlatt(2009)
USA
90 men / 33 womenMean age: 20.3Mean cig/day: 5.3Mean FTND: 2.3
12 hours Self-report Mindfulness (acceptance & non-judgement) plus “Urge Surfing”
(a) Audio recording of smoking cue exposure plus mindfulness and “urge surfing” techniques.
(b) Audio recording of smoking cue exposure plus instruction to use any technique they would normally use to cope.
(i) 24 hours(ii) 7 days
(i) 6%(ii) 10%
No significant main effect of treatment on urges or negative affect at any time point in either group. Significant reduction in smoking rates between baseline and day 7 for mindfulness group (a) but not control group (b).
Cropley et al (2007)
UK
18 men, 12 womenMean age: 25.5Mean cig/day: 17.9Mean FTND: 4.8
Overnight CO <10ppm
Guided body scanning.
(a) Audio recording of a guided body scan.
(b) Audio recording of neutral passage.
N/A N/A Desire to smoke was significantly lower in body scan group (a) compared to control (b) immediately & 5 minutes post audio intervention. Significant post-intervention reductions in irritability, restlessness and tension for body scan (a) compared to control group (b), but not for depression, stress or difficulty concentration.
May et al (2012)
UK
11 men, 16 womenMean age: 29Cig/day: ≥ 10
2 hours CO (no ppm requirement specified)
Guided body scanning.
(a) Audio recording of a guided body scan.
(b) Audio recording of instructions for mind wandering.
N/A N/A Significantly lower smoking related thoughts and smoking cravings after the body scan block (a) compared to mind wandering blocks (b).
Continued…
Participants Abstinence Abstinence Type of Experimental Control Follow up Attrition Main Findings66
Authors/ Country of Study
required Validation Intervention Conditions Conditions
Rogojanski, Vettese & Antony(2011)
Canada
36 men, 25 womenMean age: 40.3Mean cig/day:≥10Mean FTND: 4.6
None N/A Mindfulness (acceptance & non-judgement) plus “Urge Surfing”.
(a) Audio recording of smoking cue exposure plus mindfulness instructions.
(b) Audio recording of smoking cue exposure plus suppression instructions.
(i) 7 days (i) 20% No significant difference in post intervention cravings between the two groups. No significant difference in smoking rates or self-efficacy between the two groups at day 7. Negative affect, depression and nicotine dependence significantly reduced at day 7 for mindfulness (a), but not for control (b).
Ruscio et al (2016)
USA
22 men, 22 womenMean age: 44.8Mean cig/day: 15.9Mean WISDM: 55.7
None N/A Brief mindfulness practice (“Urge Surfing”, mindfulness of the breath, body, thoughts and emotions).
(a) Audio recording of one of five daily mindfulness practices for two weeks.
(b) Audio recording of one of five daily sham meditation practices for two weeks.
(i) 7 days(ii) 14 days
(i) 27%(ii) 27%
Significantly reduced negative affect, cravings immediately post-audio and cigarettes smoked per day in the brief mindfulness practice group (a) compared with sham meditation (b). No significant difference in cotinine or CO levels between the two groups.
Ussher et al (2009)
UK
31 men, 17 womenMean age: 27.8Mean cig/day: 15.5Mean FTND: 5.0
Overnight CO <10ppm
Guided body scanning & isometric exercises.
(a) Audio recording of guided a guided body scan (b) Audio recording of an isometric exercise routine.
(c) Audio recording of neutral passage
N/A N/A Desire to smoke significantly lower in body scan (a) and isometric exercise (b) groups compared to control group (c) up to 30 mins post-intervention in the lab, and up to 5 mins post-intervention in the natural environment. Irritability, difficulty concentrating and stress were reduced in the body scan group (a) compared to the control group (c) in the lab, and irritability, difficulty concentrating and restlessness were reduced in the body scan group (a) compared to the control (c) group in the natural setting.
Continued…67
Authors/ Country of Study
Participants Abstinence required
Abstinence Validation
Type of Intervention
Experimental Conditions
Control Conditions
Follow up Attrition Main Findings
Westbrook et al (2013)
USA
37 men, 17 womenMean age: 45.0Mean cig/day: 17.6Mean FTND: 5.0
12 hours CO <13ppm
Mindfulness (mindful attention, acceptance & non-judgement).
(a) Instructed to mindfully attend to smoking cue images, neutral images and aversive images.
(b) Instructed to relax and look at smoking cue images, neutral images and aversive images as naturally as possible.
N/A N/A Significantly higher self reported cravings and distress in the ‘relax and look’ at smoking images condition (b) compared to the ‘mindfully attending’ to smoking images condition (a). Reduced neural activity in craving-related brain region (sgACC).
Key: Cig/day = cigarettes smoked per day on average before the study; CO = Exhaled carbon monoxide; ppm = Parts per million; FTND = Fagerström test for nicotine dependence; sgACC = Subgenual anterior cingulate cortex; WISDN = Wisconsin Inventory of Smoking Dependence Motives
68
Table 3.2
Characteristics of cessation studiesAuthors/ Country of Study
Participants Type of Intervention
Experimental Groups
Control Groups
Duration Follow up AbstinenceValidation
Attrition* Main Findings Outcomes(% Abstinence) †
Al-Chalabi et al (2008)
UK
19 men, 21 womenMean age: 34.5 yearsMean cig/day: 19FTND: 5.2
Body Scan & Isometric Exercise
(a) Guided body scan, guided isometric exercise, behavioural support + NRT
(b) Behavioural support + NRT
8 to 12 weeks
(i) 4 weeks CO <10ppm (a) 20%(b) Not reported
No significant difference in abstinence, intensity of withdrawal symptoms or urge to smoke between intervention and control groups.
(i)(a) 45(b) 55
Altner (2002) 45 men, 72 womenMean age: 38.5 years
MBSR (a) MBSR plus NRT
(b) NRT 8 weeks (i) 6 weeks(ii) 3 months(iii) 6 months(iv) 15 months
CO rating (unspecified requirement)
(a) 0%(b) 3%
Significantly higher abstinence in MBSR group compared with control group at (i) and (iii), but not at (ii) or (iv).
(i) (ii) (iii) (iv) (a) 76 47 41 33(b) 54 34 24 25
Brewer et al(2011)
USA
54 men, 33 womenMean age: 45.9 yearsMean cig/day: 20
Mindfulness (a) Mindfulness training
(b) FFS 4 weeks (i) 6 weeks(ii) 12 weeks(iii) 17 weeks
Self report + CO < 10ppm
(a) 29%(b) 30%
Significantly higher abstinence in MT compared to FFS at (iii). Significantly greater reduction in smoking rates in MT compared to FFS at (i), (ii) & (iii).
(iii)(a) 31(b) 6
Davis et al(2007)
USA
8 men. 10 women Mean age: 45.2 yearsMean cig/day: 19.9
MBSR (a) Mindfulness instruction
N/A 8 weeks (i) 6 weeks 7 day PP +CO < 10ppm
(a) 28% Time spent doing mindfulness meditation was a significant predictor of abstinence. Significantly less symptoms of stress reported by high versus moderately compliant meditators.
(i)(a) 56
Continued…69
Authors/ Country of Study
Participants Type of Intervention
Experimental Groups
Control Groups
Duration
Follow up AbstinenceValidation
Attrition* Main Findings Outcomes(% Abstinence) †
Davis et al (2014a)
USA
98 men, 98 womenMean age: 41.7 yearsMean cig/day: 15.8
Mindfulness (a) MTS + NRT
(b) Quit line + NRT
8 weeks (i) 4 weeks(ii) 24 weeks
7 day PP + TLFB +CO < 7ppm
(a) 78%(b) 65%
Significantly higher abstinence in MTS group compared to control at (i) & (ii). Significant improvement in emotion regulation, attention control and mindfulness in MTS group compared to control.
(i) (ii)(a) 46 39(b) 25 21
Davis et al (2014b)
USA
91 men, 84 womenMean age: 44.7 yearsMean cig/day: 17.3 FTND: 4.7
Mindfulness (a) MTS + NRT
(b) FFS-E + NRT
7 weeks (i) 4 weeks(ii) 24 weeks
TLFB +CO < 7ppm
(a) 32%(b) 27%
No significant difference in abstinence between MTS and FFS-E at (i) or (ii). Significant decrease in urge to smoke, self-reported stress and experiential avoidance in MTS compared to FFS-E.
(i) (ii)(a) 35 25(b) 34 18
Gifford et al(2004)
USA
31 men, 45 womenMean age: 43 yearsMean cig/day: ≥ 10FTND: ≥ 5
ACT (a) ACT (including mindfulness skills)
(b) NRT 7 weeks (i) 6 months(ii) 1 year
24 hour PP +CO < 11ppm
(a) 39%(b) 19%
Significantly higher abstinence in ACT compared to NRT group at (ii), but no significant difference in withdrawal symptoms or negative affect.
(i) (ii) (a) 23 35(b) 11 15
Continued…
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Authors/ Country of Study
Participants Type of Intervention
Experimental Groups
Control Groups
Duration
Follow up AbstinenceValidation
Attrition* Main Findings Outcomes(% Abstinence) †
Gifford et al(2011)
USA
125 men, 178 womenMean age: 46 yearsMean cig/day: ≥ 15FTND: ≥ 5
ACT (a) ACT (including mindfulness skills) + Bupropion
(b) Bupropion 10 weeks (i) 10 weeks(ii) 6 months(iii) 1 year
7 day PP +CO < 10ppm
(a) 38%(b) 67%
Significantly higher abstinence in ACT plus Bupropion group compared to Bupropion alone group at (iii). Acceptance of internal smoking cues significantly mediated abstinence at (iii).
(i) (ii) (iii) (a) 50 26 32(b) 28 18 18
Michalsen et al(2002)
Germany
43 men, 73 womenMean age: 39 yearsMean cig/day: 25.6FTND: 4.9
MBSR (a) Educative & Cognitive therapy, counselling, NRT, MBSR
(b) Educative & Cognitive therapy, counselling + NRT
8 weeks (i) 6 weeks(ii) 3 months (iii) 6 months
CO rating (unspecified requirement)
(a) 40%(b) 40%
No significant difference in abstinence between control and experimental groups at (ii) or (iii). Significantly lower CO concentration & smoking intensity in MBSR group at (iii).
(i) (ii) (iii) (a) 74 42 41(b) 50 35 20
ACT = Acceptance & Commitment Therapy; CBI = Cognitive Behavioural Intervention; CO = Exhaled Carbon Monoxide; FFS = Freedom From Smoking Treatment; FFS-E = Enhanced Freedom From Smoking Treatment; FTND: Fagerström Test for Nicotine Dependence; MBRS = Mindfulness Based Stress Reduction; MTS = Mindfulness Training for Smokers; NRT = Nicotine Replacement Therapy; PP = Point Prevalence; ppm = Parts Per Million; SCN = Saliva Thiocyanate; TLFB = Timeline Follow Back. * Attrition refers to cumulative loss to follow-up at final contact point. † Analysis includes treatment initiators/completers (as opposed to intent-to-treat).
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3.6 Results
3.6.1 Description of acute studies
Participants in the intervention arm of the Bowen and Marlatt (2009) study took part
in a smoking cue exposure trial and were instructed to accept feelings and sensations
in a non-judgemental fashion, and use an ‘Urge Surfing’ technique whereby smokers
“ride” the urge to smoke through it’s fluctuations. Those in the control group were
simply asked to utilise any technique they would normally use to cope. Similarly,
Rogojanski, Vettese and Antony (2011) also used smoking cue exposure with either
mindfulness instructions to accept any thoughts and feelings that arise (based on
Bowen and Marlatt’s, 2009, ‘Urge Surfing’ technique), or suppression instructions to
actively avoid thoughts and feelings. Westbrook et al (2013) used a within-subjects
design, and asked participants to view three types of pictures (smoking, neutral and
aversive) and to either mindfully attend to the images, or relax and look at them as
naturally as possible. Again using a within-subjects design, smokers in the May et al
(2012) study were either instructed to allow their mind to wander during a 10-minute
audio intervention or to follow guided body scanning instructions. Participants in the
experimental group of the study by Cropley, Ussher and Charitou (2007) listened to a
10-minute audio recording of a guided body scan, and the control group listened to a
reading of natural history text. Ussher et al (2009) also required participants to listen
to either a 10-minute audio delivered guided body scan, guided isometric exercises or
the natural history text. Participants in the experimental arm of the Ruscio et al
(2016) study listened to either one of five different guided meditations (urge surfing,
mindfulness of breath, body, thoughts or emotions) on a daily basis for two weeks,
while the control condition listened to one of five different sham meditation tracks.
72
Five studies required temporary smoking abstinence (Bowen & Marlatt, 2009;
Cropley, Ussher & Charitou, 2007; May et al, 2012; Ussher et al, 2009; Westbrook et
al, 2013), and two did not (Rogojanski, Vettese & Antony, 2011; Ruscio et al, 2016).
Overnight abstinence was required for two studies (Cropley et al, 2007; Ussher et al,
2009), 12 hours for two studies (Bowen & Marlatt, 2009; Westbrook et al, 2013), and
two hours for one study (May et al, 2012). Abstinence was validated objectively via a
CO level of less than 10ppm in two studies (Cropley, Ussher & Charitou, 2007;
Ussher et al, 2009), less than 13ppm in one study (Westbrook et al, 2013), and
although measured by May et al (2012), an exact ppm reading was not specified.
Bowen and Marlatt (2009) relied on self-reported abstinence. The interventions were
administered over the course of one laboratory based session in all of the studies
except Ussher at al (2009), which took place over the course of one day in both the
lab and the participants’ natural environment, May et al (2012) over two
counterbalanced sessions on different days, and Ruscio et al (2016) which required
three lab sessions in addition to two weeks of daily practice in the participants’
natural environment. There were follow-up periods of 24 hours and 7-days in the
study by Bowen and Marlatt (2009), 7-days in the study by Rogojanski, Vettese and
Antony (2011), and 7 and 14-days in the study by Ruscio et al (2016). There were no
follow up periods in the remaining four (Cropley, Ussher & Charitou, 2007; May et
al, 2012; Ussher et al, 2009; Westbrook et al, 2013).
Intervention efficacy was measured via self-reported levels of cigarette craving/urge
to smoke in all studies, as well as levels of negative affect/distress in four studies
(Bowen & Marlatt, 2009; Rogojanski, Vettese & Antony, 2011; Ruscio et al, 2016;
Westbrook et al, 2013), withdrawal symptoms in two studies (Cropley, Ussher &
73
Charitou, 2007; Ussher et al, 2009), subsequent smoking rates in three studies
(Bowen & Marlatt, 2009; Rogojanski, Vettese & Antony, 2011; Ruscio et al, 2016),
frequency of smoking related thoughts in one study (May et al, 2012), and neural
activity in a craving-related region of the subgenual anterior cingulate cortex
(sgACC) in one study (Rogojanski, Vettese & Antony, 2011).
3.6.2 Methodological quality of acute studies
Methodological quality of the included studies was assessed in accordance with
recommendations made by the Centre for Research and Dissemination (Tacconelli,
2010) in terms of eligibility criteria, randomisation procedures, blinding of
participants and/or researchers to the treatment condition, attrition rates and how
missing data were dealt with in the analysis.
Eligibility criteria
Five studies specified that participants must smoke at least 10 cigarettes per day
(Cropley, Ussher & Charitou, 2007; Rogojanski, Vettese & Antony, 2011; Ruscio et
al, 2016; Ussher et al, 2009; Westbrook et al, 2013), and two did not stipulate any
smoking criteria (Bowen & Marlatt, 2009; May et al, 2012). Two studies required
participants to have been smoking for at least three years (Cropley, Ussher &
Charitou, 2007; Ussher et al, 2009), one specified a habit of more than two years
(Ruscio et al, 2016), and the rest did not stipulate a length of smoking criteria. In
terms of participants’ intention to quit, Westbrook et al (2013) specified that
participants must express a strong desire to quit within the following month, Bowen
and Marlatt (2009) required participants to have some interest in either cutting down
or quitting, but not currently involved in a cessation programme, and Rogojanski,
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Vettese and Antony (2011) stipulated that participants must have thought about
cutting down or tried to quit smoking in the past. The studies by Cropley, Ussher and
Charitou (2007), May et al, (2012), Ruscio et al (2016), and Ussher et al (2009) did
not specify any intention to quit criteria.
Randomisation
Where appropriate, all studies reported that participants were randomly assigned to
each condition; one specified a computer based random number generator (Ussher et
al, 2009), one involved a blocked procedure stratified by gender (Ruscio et al, 2016),
and three did not provide details of the method used for randomisation (Bowen &
Marlatt, 2009; Cropley, Ussher & Charitou, 2007; Rogojanski, Vettese & Antony,
2011). May et al (2012) and Westbrook et al (2013) used a within subjects design
where participants completed both lab based experimental and control trials in a
counterbalanced and pseudo-randomised order respectively.
Blinding
Participants in the studies by Cropley, Ussher and Charitou (2007), Ruscio et al
(2016) and Ussher et al (2009) were blind as to whether they were in the control or
experimental condition, and the mindfulness technique used by Westbrook et al
(2013) was not described to participants as a strategy for reducing smoking cravings.
There was no clear blinding of participants or researchers in the remaining three
studies (Bowen & Marlatt, 2009; May et al, 2012; Rogojanski, Vettese & Antony,
2011).
75
Attrition rates
Only three studies included a follow-up period; Bowen and Marlatt (2009) had an
attrition rate of 10% at the 7-day follow-up, Ruscio et al (2016) had an attrition rate
of 27% at both the 7 and 14-day follow up, and Rogojanski, Vettese and Antony
(2011) state that 20% of randomised participants failed to attend the 7-day follow-up.
All three report that there were no significant differences in any key demographic
variables between completers and non-completers, with Ruscio et al (2016) fully
documenting the reasons for all losses to follow-up in both the experimental and
control conditions. In terms of compliance and exclusions, Bowen and Marlatt (2009)
reported that some participants failed to complete the requested 12-hour abstinence
prior to intervention commencement, but report that their inclusion or exclusion did
not affect the significance of primary outcomes.
3.6.3 Intervention efficacy of acute studies
Bowen and Marlatt (2009) report that there was no significant main effect of the
mindfulness plus ‘urge surfing’ technique on urge to smoke or negative affect, but
that there was a significant reduction in smoking rates between baseline and 7-day
follow-up for the mindfulness but not controls. Rogojanski, Vettese and Antony
(2011) who also used mindfulness and ‘urge surfing’, found no significant reduction
in cravings between the intervention and control group immediately post intervention,
and no significant reduction in smoking rates or self-efficacy between the two groups
at day 7. Negative affect, depression and nicotine dependence were however all
significantly reduced for the mindfulness group, but not for the controls. Ruscio et al
(2016) report significant reductions in negative affect, cravings immediately post-
audio and number of cigarettes smoked per day for participants using ‘urge surfing’
76
and guided mindfulness routines for two weeks, compared with the sham meditation
control group. There was however no significant difference in cotinine or CO levels
between the two groups at follow-up.
Westbrook et al (2013) report significantly higher cravings and distress when
participants were asked to ‘relax and look’ at smoking images compared to
‘mindfully attending’ to them. Furthermore, they observed a decrease in neural
activity in a craving-related region of the subgenual anterior cingulate cortex as a
result of the mindful attention. Cropley, Ussher and Charitou (2007) reported that
desire to smoke was significantly lower in the body scan group compared to the
control group immediately after, and five minutes post audio intervention, and there
were significant main group effects for the withdrawal symptoms of irritability,
restlessness and tension (but not for depression, stress and difficulty concentrating).
The study by Ussher et al (2009) reported significantly lower ratings for strength of
desire to smoke for the body scan group compared with the control group, with desire
to smoke remaining significantly lower up to 30 minutes post audio intervention in
the laboratory, but only up to 5 minutes in the natural environment. Irritability,
difficulty concentrating and stress were reduced in the body scan compared to control
group in the laboratory setting, and irritability, difficulty concentrating and
restlessness were reduced in the body scan compared to control group in the natural
setting. May et al (2012) found that compared with instructions to allow their mind to
wander, when participants followed body scanning instructions, the frequency of
smoking related thoughts and cravings were significantly reduced. Levels of both
however rebounded above baseline levels following a final block of mind wandering
instructions.
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To summarise, the mindfulness plus ‘urge surfing’ technique returned mixed results
for negative affect, cravings and smoking behaviour (Bowen & Marlatt, 2009;
Rogojanski, Vettese & Antony, 2011), and whilst the study by Ruscio et al (2016)
found significant reductions in negative affect and cravings, the study contained
potential reliability issues regarding actual reductions in smoking rates. The guided
body scan technique showed a reduction in cravings and some withdrawal symptoms
(Cropley, Ussher & Charitou, 2007; May et al, 2012), but these effects were
relatively short lived – especially outside of the controlled setting of a laboratory
(Ussher et al, 2009). Finally, the results of the mindful awareness technique showed a
positive impact on reducing self-reported levels of craving and distress, with findings
supported by neuroimaging evidence (Westbrook et al, 2013).
3.6.4 Description of cessation studies
Whilst all studies contained an element of mindfulness, the interventions were
administered in a number of different ways: one used a guided body scan (Al-Chalabi
et al, 2008), three used Mindfulness Based Stress Reduction (MBSR; Altner, 2002;
Davis et al, 2007; Michalsen et al, 2002), two used Acceptance and Commitment
Therapy (ACT; Gifford et al, 2004; 2011), two used Mindfulness Training for
Smokers (MTS; Davis et al, 2014a; 2014b), and one used a generic form of
mindfulness training (Brewer et al, 2011). Many of the studies also combined
mindfulness with other cessations methods: five with NRT (Al-Chalabi et al, 2008;
Altner, 2002; Davis et al, 2014a; 2014b; Michalsen et al, 2002), one with Bupropion
(Gifford et al, 2011), one with isometric exercises (Al-Chalabi et al, 2008), one with
educative and cognitive therapy, and counselling (Michalsen et al, 2002), and one
with behavioural support (Al-Chalabi et al, 2008).
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The duration of the studies varied: one study lasted four weeks (Brewer et al, 2011),
two lasted seven weeks (Davis et al, 2014b; Gifford et al, 2004), four lasted eight
weeks (Altner, 2002; Davis et al, 2007; Davis et al, 2014a; Michalsen et al, 2002),
one lasted 10 weeks (Gifford et al, 2011) and one lasted eight to 12 weeks depending
on when participants set their quit date (Al-Chalabi et al, 2008). Follow-up periods
ranged from four weeks (Al-Chalabi et al, 2008) to 15 months (Altner, 2002), with
contact made between once (Al-Chalabi et al, 2008) and four times (Altner, 2002)
during these periods. Abstinence was validated objectively in all of the cessation
studies, with four requiring an CO level of less than 10ppm (Al-Chalabi et al, Brewer
et al, 2011; Davis et al, 2007; Gifford et al, 2011), two requiring less than 7ppm
(Davis et al, 2014a; 2014b), one requiring less than 11ppm (Gifford et al, 2004), and
two not specifying an exact CO level (Altner, 2002; Michalsen et al, 2002). Three
studies further verified abstinence via 7-day point-prevalence (Davis et al, 2007;
Davis et al, 2014a; Gifford et al, 2011), one via 24-hour point-prevalence (Gifford et
al, 2004), two via timeline followback (TLFB; Davis et al, 2014a; 2014b) and one via
self-report (Brewer et al, 2011).
The efficacy of the cessation programmes was measured objectively via
biochemically verified abstinence in all studies, as well as self-reported urge to
smoke in two studies (Al-Chalabi et al, 2008; Davis et al, 2014b), nicotine
withdrawal symptoms in two studies (Al-Chalabi et al, 2008; Gifford et al, 2004),
subsequent smoking rates in two studies (Altner, 2002; Michalsen et al, 2002),
negative affect/distress in two studies (Davis et al, 2007; Davis et al, 2014b), and
emotion regulation/attention control in one study (Davis et al, 2014a).
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3.6.5 Methodological quality of cessation studies
Eligibility criteria
Most studies detailed some kind of criteria, with eight specifying that participants
must smoke at least 10 cigarettes a day (Brewer et al, 2011; Davis et al, 2007; Gifford
et al, 2004; Michalsen et al, 2002), two specifying at least five per day (Davis et al,
2014a; 2014b), one stipulating at least 15 per day (Gifford et al, 2011), and two not
stipulating any smoking criteria (Al-Chalabi et al, 2008; Altner, 2002). One study
required participants to have been smoking for at least 3 years (Michalsen et al,
2002;), two specified a habit of more than one year (Gifford et al, 2004; 2011), and
the rest did not stipulate a length of smoking criteria.
In terms of participants’ intention to quit, Brewer et al (2011) required participants to
have an interest in stopping smoking, Davis et al (2014a & 2014b) state that
participants must have a high motivation to quit and Michalsen et al (2002) required a
willingness to give up smoking. The other studies (Al-Chalabi et al, 2008; Altner,
2002; Davis et al, 2007; Gifford et al, 2004; 2011) did not explicitly state that
participants must have had any intention to quit, although it could be argued that only
participants wishing to quit would enrol on a smoking cessation programme.
Randomisation
The majority of studies reported that participants were randomly assigned to each
condition; three used a computer based random number generator (Al-Chalabi et al,
2008; Brewer et al, 2011; Gifford et al, 2011), one used random draws (Davis et al,
2014a), and two did not provide details of the method used for randomisation (Davis
et al, 2014b; Gifford et al, 2004). Of the remainder, Altner (2002) and Michalsen et al
80
(2002) allowed participants to choose whether or not they wished to take part in the
MBSR training, and Davis et al (2007) only had an experimental group.
Blinding
Altner (2002) and Michalsen et al (2002) allowed participants to choose which
intervention they took part in, therefore blinding was not applicable. Study recruiters
were blind at the point of recruitment and participants were blind until after their
baseline visit in Al-Chalabi et al (2008), and study co-ordinators were only informed
of participants’ group assignments after randomisation in Gifford et al (2011). There
was no clear blinding of participants or researchers in the remaining five studies
(Brewer et al, 2011; Davis et al, 2007; 2014a; 2014b; Gifford et al, 2004).
Attrition rates
Attendance at cessation programme sessions in the experimental groups ranged from
85% (Davis et al, 2007) to 67% (Davis et al, 2014b), and from 78% (Brewer et al,
2011) to 64% (Davis et al, 2014b) in the control groups. Altner (2002), Gifford et al
(2011) and Michalsen et al (2002) do not clearly or fully report session attendance
rates. Where measured, compliance and adherence outside of formal meetings was
based solely on self-reporting in all studies.
All of the cessation studies reported attrition in both intervention and control groups
compared to total randomised participants, with the exception of Al-Chalabi et al
(2008) who did not report attrition in the control group. Attrition rates reported here
refer to the cumulative loss to follow-up at final contact point compared to the total
number of participants randomised. Rates in the experimental conditions varied from
81
0% (Altner, 2002) to 78% (Davis et al, 2014a), and ranged between 3% (Altner,
2002) and 67% (Gifford et al, 2011) in the control conditions. Possible reasons for
attrition were analysed and reported in seven studies (Altner, 2002; Brewer et al,
2011; Davis et al, 2007; Davis et al, 2014a; 2014b; Gifford et al, 2004 & 2011).
Reasons were not reported by Michalsen et al (2002) or Al-Chalabi et al (2011),
however the authors of the latter study maintain that it was a pilot randomised control
trial with a pragmatic design focusing on the feasibility of the intervention rather than
smoking outcomes.
Exclusions and their reasons were reported in all of the cessation studies except
Altner (2002) and Michalsen et al (2002). In terms of missing data, five studies used
intent-to-treat analysis (Brewer et al, 2011; Davis et al, 2007; Davis et al, 2014a;
2014b; Gifford et al, 2011), and Gifford et al (2004) used Generalized Estimating
Equations (GEE) to replace missing data as well as an analysis assuming all missing
data were relapse cases. Gifford et al (2011) also used GEE which was further
verified using mixed effects nominal logistic regression, and Brewer et al (2011)
handled missing data with casewise deletion. Missing data were simply excluded on a
case-by-case basis from analysis by Altner (2002) and Michalsen et al (2002). A risk
of bias summary can be seen in figure 3.3.
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Ran
dom
sequ
ence
gen
erat
ion
(sel
ectio
n bi
as)
Allo
catio
n co
ncea
lmen
t (se
lect
ion
bias
)
Blin
ding
of p
artic
ipan
ts a
nd p
erso
nnel
(p
erfo
rman
ce b
ias)
Blin
ding
of o
utco
me
asse
ssm
ent
(det
ectio
n bi
as)
Inc
ompl
ete
outc
ome
(attr
ition
bia
s)
Sel
ectiv
e re
porti
ng (r
epor
ting
bias
)
Al-Chalabi et al (2008)
Altner (2002)
Brewer et al (2011)
83
Davis et al (2014a)
Davis et al (2014b)
Gifford et al (2004)
Gifford et al (2011)
Michalsen et al (2002)
Figure 3.2 Risk of bias summary for cessation studies (Generated via Review Manager, 2014)
Intervention delivery
Six of the cessation studies reported that fully trained instructors delivered the
interventions (Altner, 2002; Brewer et al, 2011; Davis et al, 2007; Gifford et al, 2004;
2011; Michalsen et al, 2002). One was delivered by individuals who had completed a
short 2-day course, but had no addiction training (Davis et al, 2014a), one used staff
working at a smoking cessation clinic with no prior training in the mindfulness
technique used (Al-Chalabi et al, 2008), and it was unclear who delivered the
intervention in one study (Davis et al, 2014b). As per the extended CONSORT
guidelines for assessing RCTs of non-pharmacologic treatment (Boutron, Moher,
Altman, Schulz & Ravaud, 2008), precise descriptions of the different components of
the interventions are required in order to determine which elements are most
effective, and for accurate replication in the development of future interventions.
Only one study however reported full, clear details of the schedule and content of
individual programme sessions (Brewer et al, 2011), and a further five reported a
84
moderate level of detail (Altner, 2002; Davis et al, 2014a; 2014b; Gifford et al, 2004;
2011). One study simply states that the MBSR training was delivered “in the usual
manner” without any further elaboration (Davis et al, 2007), and two studies did not
provide any details (Al-Chalabi et al, 2008; Michalsen et al, 2002).
3.6.6 Intervention efficacy of cessation studies
Abstinence
When looking at analysis based on treatment initiators (TI) only, four studies reported
significantly higher abstinence rates in the intervention group compared to controls at
the final follow-up: Brewer et al (2011) reported a difference in abstinence rates at 17
weeks of 31% for the mindfulness training group versus 6% for the FFS group, Davis
et al (2014a) reported a difference in abstinence rates at 24 weeks of 39% for the
MTS plus NRT group compared to 21% for the quit line plus NRT group, Gifford et
al (2004) reported a difference at 1 year of 35% for the ACT group versus 15% in the
NRT group, and Gifford et al (2011) also reported a difference at 1 year of 32% in
the ACT plus bupropion group versus 18% in the bupropion only group. The same
four studies were then examined using intention-to-treat (ITT) analysis where those
who couldn’t be followed up were assumed to have resumed smoking (Hughes,
Keely, Niaura, Ossip-Klein, Richmond & Swan, 2003). This resulted in only two of
the studies continuing to show a significant difference between the intervention and
control groups; 22% abstinence in the intervention group versus 4% in the control
group in the Brewer et al (2011) study, and 19% versus 4% abstinent in the Gifford et
al (2011) study. There was no significant difference in the abstinence rates between
the intervention and control groups reported in the studies by Al-Chalabi et al (2008),
Altner (2002), Davis et al (2014b), or Michalsen et al (2002) at final follow-up using
85
TI or ITT analysis. Davis et al (2007) did not have a control arm in the design of their
trial, but report an abstinence rate of 56% at the six week post intervention follow-up,
with time spent practicing mindfulness mediation being a significant predictor of
abstinence.
Meta-analysis was performed on the dichotomous abstinence/relapse outcome of all
of the cessation studies except Davis et al (2007), due to the lack of a control group.
Summary statistics are expressed in terms of Relative Risk (RR) with 95%
confidence intervals (CI) for abstinence in the intervention versus control group at
final follow-up, using ITT analysis. The RR was calculated from the: (number of
participants who quit smoking in the intervention group/number of participants
randomised to intervention group) divided by (number of participants who quit
smoking in control group/number of participants randomised to the control group).
An RR greater than one favoured the intervention group and indicated that more
participants had successfully quit in the treatment group compared to the control
group at final follow-up. The results indicated that all of the studies except Al-
Chalabi et al (2008) favoured the intervention over control arm of the trials (see table
3.3).
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Table 3.3
Forest plot of RR (with 95% CI) for abstinence versus relapse outcomes in cessation studies (Generated via Review Manager, 2014).
Study Intervention n/N*
Control n/N* WeightRisk Ratio
M-H, Random, 95% CIRisk Ratio
M-H, Random, 95% CI
Al-Chalabi et al (2008)
9/20 11/20 17.3% 0.82 [0.44, 1.53]Altner (2002) 16/49 16/65 15.7% 1.33 [0.74, 2.38]Brewer et al (2011) 9/41 2/47 6.0% 5.16 [1.18, 22.52]Davis et al (2014a) 23/105 12/91 17.0% 1.66 [0.88, 3.15]Davis et al (2014b) 17/68 12/67 16.6% 1.40 [0.72, 2.69]Gifford et al (2004) 7/33 5/43 9.8% 1.82 [0.64, 5.24]Gifford et al (2011) 25/130 10/173 15.7% 3.33 [1.66, 6.68]Michalsen et al (2002)
21/53 12/63 17.7% 2.08 [1.13, 3.82]
Total (95% CI) 127/499 80/569 100% 1.70 [1.20, 2.40]
Heterogeneity: χ2 = 12.81, df = 7 (p = .08); I2 = 45%Test for overall effect: Z = 3.00 (p = 0.003)* n = Abstinent; N = Relapsed
0.01 0.1 1 10 100 Favours Control Favours Intervention
87
Data were pooled using a random effects statistical model as it allows for both within-
study and between studies variation (Deeks, Higgins, Altman & Green, 2011), and the
resulting overall estimate of relative risk based on eight studies was 1.70 (95% CI
1.20 – 2.40). This indicates that participants were 70% more likely to be abstinent if
they had been randomised to the intervention versus the control arm of a trial (p
< .01). In terms of heterogeneity, the χ2 statistic is non-significant, and an I2 of 45%
suggests a moderate amount of heterogeneity exists between the studies. This is
expected due to the huge difference in final post-cessation measurement point
between the studies. Following a sub-analysis excluding the study by Al-Chalabi et al
(2008) however, the heterogeneity of the pooled data decreased to an acceptable level
(χ2 = 6.88, df = 6, p = .33, I2 = 13%), the RR increased to 1.88 (95% CI 1.40 – 2.52)
and the overall effect became more significant (Z = 4.23, p < .0001).
To summarise, conclusions from this meta-analysis must been drawn tentatively due
to the small number of included studies, differences in length of follow-up and the
majority having very small sample sizes. However, with the exception of Al-Chalabi
et al (2008), the pooled data of seven studies (Altner, 2002; Brewer et al, 2011; Davis
et al, 2014a; 2014b, Gifford et al, 2004; 2011; Michalsen et al, 2002) favoured the
intervention over control arm for smoking abstinence outcomes.
Secondary outcome measures
Al-Chalabi et al (2008) found no significant difference in withdrawal symptoms or
urge to smoke between the group who received the body scan/isometric exercise
intervention as well as the behavioural support and NRT offered to participants in
both groups. Davis et al (2014a) reported a significant improvement in emotion
88
regulation, attention control and mindfulness in MTS plus NRT group compared to
the quit line plus NRT control group, and Davis et al (2014b) found a significant
decrease in urge to smoke, self-reported stress and experiential avoidance in the MTS
plus NRT intervention compared with the FFS-E plus NRT control group. Gifford et
al (2004) reported no significant difference in withdrawal symptoms or negative
affect in the ACT group compared with the NRT only control group, and again
following ACT plus bupropion, Gifford et al (2011) report that withdrawal symptoms
and negative affect were not significant mediators of smoking outcomes. They did
however find that smoking-related acceptance and the therapeutic relationship were
significant mediators of abstinence status at the 1 year follow up. With only a
mindfulness instruction group and no control, Davis et al (2007) found that highly
compliant meditators reported significantly reduced post-quit stress levels compared
to moderately compliant meditators, and no difference in levels of affective distress
between the two groups.
The results of the secondary outcome measures are relatively mixed, with the
mindfulness training seemingly leading to a positive impact on negative affect, and
smoking rates, but not always long term abstinence (Brewer et al, 2011; Davis et al,
2014a; 2014b; Michalsen et al, 2002), and the ACT interventions (Gifford et al, 2004;
2011) resulting in significantly increased abstinence outcomes, but without the
associated benefits to negative affect or reduced withdrawal symptoms.
3.7 Discussion
This review was conducted with the aim of evaluating the efficacy of interventions
that utilise mindfulness techniques as an aid to permanent smoking cessation or the
89
reduction of cigarette cravings and associated nicotine withdrawal symptoms in
temporarily abstinent smokers. The acute interventions that used acceptance based
instructions (Westbrook et al, 2013) or a guided body scan (Cropley, Ussher &
Charitou, 2007; May et al, 2012; Ussher et al, 2009) produced significant short-term
reductions in cravings, however the ‘urge surfing’ technique returned mixed results
(Bowen & Marlatt, 2009; Rogojanski, Vettese & Antony, 2011; Ruscio et al, 2016).
One potential reason for the lack of significant findings in the urge surfing studies by
Bowen and Marlatt (2009) and Rogojanski, Vettese and Antony (2011), is that
participants rated their level of nicotine dependence as low or low to moderate on the
Fagerström Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker &
Fagerström, 1991). Previous research has linked a higher FTND score with increased
cue reactivity (Payne, Smith, Sturges & Holleran, 1996; McClernon, Kozink & Rose,
2008; Vollstädt‐Klein, Kobiella, Bühler, Graf, Fehr, Mann & Smolka, 2011);
therefore participants’ nicotine dependence may have been too low for the cue
induction process to be effective. This is supported by the significant reduction in
cravings observed by Westbrook et al (2013) who also used cue induction, but where
participants reported moderate levels of nicotine dependence.
The effects of the body scan interventions were relatively short lived; up to 5 minutes
post-intervention in Cropley, Ussher and Charitou (2007), up to 30 minutes post-
intervention in the laboratory setting in the study by Ussher et al (2009), reducing to
only 5 minutes when used in participants’ natural environment, and only during the
10-minute body scanning block in the study by May et al (2012). Urges are
nevertheless episodic in nature, rather than chronic experiences, with temptation
episodes lasting on average 16.29 minutes (Shiffman, Engberg, Paty, Perz, Gnys,
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Kassel & Hickcox, 1997). Further research would therefore be useful to examine
whether a brief guided body scan may be sufficient to resist the urge to smoke long
enough for the desire to pass.
The difference in efficacy based on where participants used the guided body scan
intervention may indicate that it is susceptible to interference from increased
environmental stimuli that were not present in the lab setting. This is supported by the
cognitive processing model of cravings (Tiffany, 1999), which argues that a craving
episode alone requires a high level of cognitive processing due to an environmental
obstacle (e.g. forced abstinence) blocking a normally automatized sequence of craving
followed by smoking. This non-automatic processing commands increased mental
effort that is restricted by limited cognitive capacity, and consequently interferes with
other cognitively demanding tasks such as following the body scan instructions in the
presence of additional competing environmental distractions. Alternatively, when the
guided body scan was used in the participants’ natural environment, it was the second
time that it had been used by the same individual on the same day. This highlights the
need for future research to identify whether repeated use of all of the acute
interventions (e.g. within the same day, or across weeks or months), would lead to
greater benefits with increased practice, or whether a plateau effect would occur as the
novelty of the interventions reduces.
Of the cessation studies, four out of nine reported significantly higher abstinence in
the intervention arm of the trials at final follow-up points (Brewer et al, 2011; Davis
et al, 2014a; Gifford et al, 2004; 2011), however a major problem with most of the
cessation studies was participant attrition. Schulz and Grimes (2002) discuss how a
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loss to follow-up of 5% or less in a randomized trial is probably of little concern, but a
loss of 20% or more presents a serious threat to validity and concern for the
possibility of bias. Excluding the study by Altner (2002) with 0% and 3% attrition in
the experimental and control conditions respectively, the lowest attrition rate from an
intervention group in the other studies was 20% (Al-Chalabi et al, 2008) and the
highest was 78% (Davis et al, 2014a). Schulz and Grimes (2002) also argue that
differential rates of attrition between comparison arms of a trial can cause ‘major
damage’ to internal validity, so while there was no difference in attrition between the
intervention and control group in one study (40% in both arms; Michalsen et al,
2002), there was a 29% difference in attrition rates between the two groups in Gifford
et al (2011). This suggests that despite most of the studies providing details of
attrition and reasons for exclusions, both internal validity and bias are potential issues
when drawing conclusion from the results.
Attendance at cessation programme sessions also varied considerably between the
studies, and between the intervention and control arms of the trials. This is significant
in light of a study by Dorner, Tröstl, Womastek and Groman (2011), who looked at
predictors of smoking cessation success and concluded that participating in a greater
number of programme sessions increased the chances of abstinence from 12% to
61%. Variability in attendance, and a lack of clear reporting of attendance by Altner
(2002), Gifford et al (2011) and Michalsen et al (2002) further constitute a potential
source of bias. Where measured, compliance and adherence to prescribed practices
outside of formal meetings was also based solely on self-reporting, and may therefore
have been subject to over estimation due to response bias. Adherence to the guided
body scan practice in the Al-Chalabi et al (2008) study appears to have been
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particularly problematic, with very few participants of the already small sample size
downloading the body scan mp3 file (30%). The authors argue that the trial
deliberately employed a pragmatic design, and report that staff members at the
smoking cessation clinic were not trained to encourage the use of the intervention.
This resulted in a very low uptake of the mindfulness intervention, and appears to
have led to the marginal favouring of the control arm as both intervention and control
groups effectively received the same basic treatment and support.
Davis et al (2007) also found that adherence to mindfulness meditation was a
significant predictor of abstinence, and that highly compliant meditators reported
significantly less stress compared with moderately compliant meditators. This again
highlights how important adherence to treatment is in producing any sustained
benefits for smoking outcomes, and is a commonly reported problem in the literature.
It also supports the need to carefully consider how mindfulness based techniques are
built into smoking cessation programmes, as additional encouragement may be
needed to maintain necessary levels of technique use. Davis et al (2007) also report
that participants declaring at baseline a “strong interest in learning meditation” had
significantly higher point prevalence abstinence. This suggests that this type of
intervention may not be appealing to all smokers, and that an openness to the ideas
associated with meditation may be a pre-requisite for compliance and adherence.
There was little evidence of blinding in the cessation studies, with five of the eight
studies with a control arm showing no attempt to blind either participants or
researchers to allocated conditions, and two allowing participants to choose their
preferred intervention group. Whilst the blinding of participants and those delivering
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the intervention is not always possible once the treatment has begun, double blinding
should at least be possible at the point of randomisation in order to avoid selection
bias. As stated in the CRDs guidance for carrying out reviews (Khan, ter Riet, Popay,
Nixon & Kleijnen, 2001), lack of adequate blinding is a serious methodological issue,
as performance bias can arise from “unintended intervention or cointervention not
specified in the study protocol” (p. 4). This is supported by a large meta-analysis
review by Schulz, Chalmers, Hayes and Altman (1995), who found that compared
with studies reporting adequate blinding, inadequate treatment concealment can lead
to larger estimates of intervention effects (p< .001) and odds ratio exaggeration of up
to 41%. The results of the cessation studies included in the current review are
therefore likely to contain selection, concealment and performance bias to some
degree.
The cessation interventions contained a high level of heterogeneity in terms of course
content, with different studies incorporating different elements of mindfulness
training in a variety of ways. The need for clarity in the description of content and
delivery of the interventions is crucial in determining which aspects of mindfulness
training are effective in promoting smoking abstinence. In this respect, the majority of
cessation studies included in the current review do provide a moderate level of
intervention detail or reference the appropriate syllabus followed, however three
studies provide no detail at all. Michie, Hyder, Walia and West (2011), have
developed a reliable taxonomy of behaviour change techniques for smoking cessation
interventions that aims to provide a consistent terminology for describing intervention
content. Future mindfulness based RCTs may benefit from using this taxonomy as a
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framework for establishing the ‘active ingredients’ of the interventions, and
establishing associations between intervention content and outcome.
1. Conclusions regarding the long-term efficacy of mindfulness based
interventions on abstinence is difficult to determine from the studies currently
available, as there is a large amount of heterogeneity in length of follow-up,
and therefore a lack of abstinence data at comparable time points. According
to a review of measures of abstinence in clinical trials by Hughes et al (2003),
the recommended length of follow-up for trials where smokers set a definite
quit date is 6 and/or 12 months. Of the cessation studies included in the
current review, only four meet these criteria; Michalsen et al (2002) reported
abstinence at 6 months, and Altner (2002) and Gifford et al (2004; 2011)
reported abstinence at 1 year post-intervention. The results of the Altner
(2002) and Michalsen et al (2002) study are not significant for abstinence at
final follow-up, and even though both of the Gifford et al (2004; 2011) studies
report that the intervention participants were still significantly more likely to
be abstinent at one year, the risk of relapse after this time remains around 30%
(Etter & Stapleton, 2006). Future research would therefore benefit from the
collection of follow-up data over a longer period.
A systematic review by Stead and Lancaster (2012) examined cessation rates of
interventions that combined behavioural support and pharmacotherapy, and found an
increased chance of successful abstinence of between 70% and 100% compared to
brief advice or support. In line with this, the results of the meta-analysis of the current
review also indicated that participants were 70% more likely to be abstinent at final
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follow-up if randomised to the intervention arm of the studies compared to the control
arm. This suggests that mindfulness based interventions have the potential to produce
efficacy levels which are comparable to other behavioural interventions. However,
despite an improvement in the methodological quality of the cessation studies in more
recently published papers, all of those included in the review contained some
methodological limitations. Whether the issues related to small sample sizes, high
attrition rates, non-adherence to prescribed practices or a lack of blinding, it is evident
that there were numerous sources of potential bias in the data and reporting.
Furthermore, high levels of heterogeneity with regards to intervention protocol make
it difficult to determine which mindfulness element is responsible for the observed
effects, with some studies providing very limited detail of the course content (e.g.
Davis et al, 2007). The acute studies utilising a single mindfulness facet returned
mixed results in terms of their ability to alleviate cravings, reduce smoking rates and
negative affect, with the body scan and acceptance based instructions producing more
positive outcomes than the urge surfing technique. This suggests that these individual
‘mindfulness’ based techniques may be useful adjuncts to smoking cessation,
however the heterogeneity of the cessation studies means it is not currently possible to
draw any firm conclusions regarding the efficacy of mindfulness interventions for
long-term smoking cessation. In light of the often low methodological quality and
heterogeneous nature of the studies, the ability of this systematic review to fully
compare the studies on an equal basis is heavily compromised, and future RCTs need
to address these issues to produce more definitive and credible findings.
3.8 Further Research Questions
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In terms of the focus of this thesis, the acute studies cited in this review that used a
10-minute guided body scan intervention report a significant reduction in cigarette
cravings and smoking related thoughts (May et al, 2012), desire to smoke and tobacco
withdrawal symptoms post-intervention (Cropley, Ussher & Charitou, 2007; Ussher et
al, 2009). However, factors that remain unclear include the exact mechanisms
responsible for the observed reduction in cravings and withdrawal symptoms, exactly
how long the effect lasts, whether the effect will wear off with continued use, how it
could be incorporated into a real life quit attempt, and whether there could be a
synergy between body scanning and traditional NRT. It is the aim of this thesis to
examine and address these questions in order to explore the feasibility and best use of
the guided body scan as an adjunct to permanent smoking cessation.
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_____________________________________________________________________
CHAPTER 4
STUDY 1: EXPLORATION OF THE SYNERGISTIC EFFECT OF NICOTINE
REPLACEMENT THERAPY AND A GUIDED BODY SCAN ON
CIGARETTE CRAVINGS AND NICOTINE WITHDRAWAL
4.1 Introduction
The aim of Nicotine replacement therapy (NRT) is to temporarily replace much of the
nicotine from cigarettes, thereby reducing the motivation to smoke by moderating
many of the associated physiological and psychomotor withdrawal symptoms (Fant,
Owen & Henningfield, 1999). NRT is accepted and recommended as an effective
treatment for people seeking pharmacological help to quit smoking (Cahill et al,
2013), with a systematic review of 117 trials by Stead et al (2012) finding that NRT
alone returned a pooled estimate for abstinence of RR 1.60 (95% CI 1.51 - 1.68).
However whilst a high dose treatment regimen of NRT patches has been shown to
almost completely eliminate cravings and withdrawal symptoms, and improve
abstinence rates over a placebo, substantial relapse rates of between 30 – 59% still
occur (e.g. Dale, Hurt, Offord, Lawson, Croghan & Schroeder, 1995; Shiffman,
Ferguson, Gwaltney, Balabanis & Shadel, 2006; Stead et al, 2012).
Reasons for this relatively high rate of relapse have centred on the possibility that
patches simply eliminate underlying background symptoms without protecting the
smoker from acute reactivity to situational cues (Shiffman, Paty, Gnys, Kassel &
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Hickcox, 1996). For example, a study by Tiffany, Sanderson-Cox and Elash (2000)
examined the impact of nicotine patches on cue-elicited cravings in abstinent
smokers, and report that while the NRT effectively reduced abstinence induced
cravings, it had no significant impact on cravings generated by smoking related cues.
They conclude that cravings originating from nicotine abstinence and those that stem
from smoking related cues appear to make independent contributions to overall levels
of cigarette cravings in smokers.
As discussed in chapter two, mindfulness-based interventions have been proposed as a
potentially useful tool in helping smokers to quit via the promotion of flexibility of
awareness and reduced reactivity to smoking cues during emotionally challenging
situations (e.g. Bowen, Witkiewitz, Dillworth & Marlatt, 2007; Breslin, Zack &
McMain, 2002; Chambers, Lo & Allen, 2008; Lutz, Slagter, Rawlings, Francis,
Greischar & Davidson, 2009; Chiesa, Serretti & Jakobsen, 2013). In other words,
mindfulness practice may reduce emotional volatility to smoking related cues during
high-risk situations and consequently counteract the impulsive behaviour that would
normally lead to a smoking relapse. Furthermore, a recent review by Stead, Koilpillai,
Fanshawe and Lancaster (2016) found that combining pharmacotherapy with
behavioural interventions (such as mindfulness) increased the chances of successful
smoking cessation compared with usual care, with meta-analysis indicating an RR of
1.83 (95% CI 1.68 - 1.98). This suggests that while the NRT element of an
intervention may counteract the negative consequences of nicotine abstinence, the
added behavioural element may improve efficacy further by negating the negative
impact of smoking related cues on cigarette cravings.
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Building on the work of Cropley et al (2007) and Ussher et al (2009), which both
found that a brief guided body scan had the ability to significantly reduce cigarette
cravings and nicotine withdrawal symptoms, the current study aims to explore the
effect of combining NRT transdermal patches with a 10 minute audio guided body
scan on cravings and withdrawal symptoms in temporarily abstinent smokers. It is
hypothesised that there will be a synergistic effect when NRT is combined with the
guided body scan, and that this condition will result in a significantly greater
reduction in ratings of craving and withdrawal symptoms compared with the
administration of a placebo patch or listening to a control audio.
4.2 Methodology
4.2.1 Participants
A G-power calculation indicated that a sample size of 72 participants was needed for
a power of 95% (Cohen, 1988), with a significance level of .05 and an effect size
of .30. Opportunity sampling was used to select the participants for the study, who
consisted of 72 smokers (n = 38 male, 34 female), aged between 18 and 63 years (M =
26.8, SD = 9.6) who smoke at least 10 cigarettes a day (M = 13.1, SD = 3.2), and who
have smoked for at least three consecutive years (M = 10.8, SD = 9.1). Participants
were recruited using posters advertising the study (appendix 3) placed in private
companies around the Maidenhead and Slough areas, and on the University of Surrey
campus. They were paid £10 on completion of the experiment for their involvement in
the study.
4.2.2 Design
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The aim of this randomised controlled trial (RCT) was to explore whether combining
a 10 minute guided body scan with NRT could produce a synergistic effect in
reducing cigarette cravings and tobacco withdrawal symptoms. The placebo
controlled study design consisted of two levels of independent variable: i) the
administration of an active nicotine patch or a placebo nicotine patch, and ii)
completing either the 10 minute guided body scan or listening to 10 minutes of the
control text reading. The dependent variable was participants’ ratings of desire to
smoke and tobacco withdrawal symptoms given immediately after the task, and at 5,
10, 20 and 30 minutes post-task.
4.2.3 Interventions
The guided body scan
After receiving brief verbal instructions about what the guided body scan would entail
(e.g. “the aim of this recording is to increase awareness of your body and mind, of
your whole self”), participants were guided through a 10 minute audio recording of a
seated body scan routine based on that used originally by Cropley et al (2007). They
were instructed to focus on their breathing by concentrating their attention on the
abdominal area and to become aware of the way they are breathing and the sensations
associated with breathing (e.g. “feel the breath that enters your body by your nostrils
or by your mouth”). This focus of awareness was gradually moved to other areas of
the body, before attention was brought back into the room in which the participant
was sat to gently bring them back to being conscious of their surroundings (see
appendix 4 for full verbatim narrative).
Control audio
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The control audio condition involved participants listening to a 10 minute recorded
extract of a natural history text (White, 1997). The extract narrative centres on the
geographical and geological features of Selborne in Hampshire, England, has been
used previously by Cropley et al (2007), who report that those who listened to the
recording found it to be a neutral yet relaxing passage.
Nicotine replacement therapy
Nicotine replacement was delivered via a NiQuitin® 21mg transdermal patch
(GlaxoSmithKline Plc.), with each 22cm2 patch containing 114mg of nicotine,
equivalent to 5.1 mg/cm2 of nicotine. This is the recommended dosage for individuals
smoking more than 10 cigarettes per day (as specified by the eligibility requirements
of the study). Following transdermal application, the skin rapidly absorbs nicotine
released initially from the patch adhesive. The plasma concentrations of nicotine
reach a plateau within 2 hours after initial application (Berner & John, 1994), with
relatively constant plasma concentrations persisting for 24 hours or until the patch is
removed. The placebo patches were identical in appearance to the active nicotine
patches, but delivered no nicotine to the wearer at any time.
4.2.4 Measures
Fagerström Test for Nicotine Dependence (FTND; Heatherton et al, 1991)
The FTND is a 6-item self-report measure (appendix 5) of dependency on nicotine
that is closely related to biochemical indices of heaviness of smoking. The reliability
of the questionnaire has been investigated using a sample of students, academic and
administrative staff by Etter, Vu Duc and Perneger (1999), who report an internal
consistency alpha of .70, test re-test reliability of .85 (p > 0.001), and a single factor
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structure accounting for 41.4% of total variance. In terms of predictive validity, they
found that the number of cigarettes smoked per day successfully predicted abstinence
at follow up, although the odds of quitting decreased by 5% for each additional
cigarette smoked per day. Cross validation also showed that all variables were
strongly associated with saliva cotinine levels, with a relative validity of 95% of
variance explained by the items on the FTND. The FTND was administered to
participants in the present study to establish their background level of tobacco
dependency and explore whether this had any impact on the effect of the
interventions.
Mood and Physical Symptoms Scale (MPSS; West & Hajek, 2004)
The MPSS (appendix 6) is specifically designed to assess self-rated levels of the
nicotine withdrawal symptoms of irritability, tension, depression, restlessness,
difficulty concentrating and stress. Each is rated on a seven-point scale, for example
“how tense do you feel right now?” (1 = not at all, 4 = somewhat, 7 = extremely) with
the additional question of “how strong is your desire to smoke right now?” added for
the purposes of the present study. West and Hajek (2004) report factor loadings for
each scale on the MPSS to be high (with the exception for ‘hunger’ which was not
included in the analysis of the present investigation), and a coefficient alpha of .78
indicating a high degree of overall coherence and reliability.
4.2.5 Procedure
Upon expressing interest in taking part in the study, and prior to abstinence,
participants were screened via e-mail to check their eligibility status by confirming
that they were within the correct age range (18 – 65), had been smoking long enough
(more than 3 consecutive years), and smoked an average of more than 10 cigarettes
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per day. They were also required to be able to read and write in English, not be
receiving treatment for mental health problems, not pregnant or currently trying to
conceive.
Once eligibility was established, smoking status was verified via an expired carbon
monoxide (CO) concentration of ≥15ppm (Middleton & Morice, 2000). They were
then given a participant information sheet to read (appendix 7), a consent form to sign
(appendix 8), and an opportunity to ask any questions. They then completed the
Fagerström Test for Nicotine Dependence (FTND; Heatherton et al, 1991), and were
asked to provide further demographic information on age, gender, ethnic group,
marital status, occupation, whether they would like to give up smoking, how long they
have been smoking, and how many serious quit attempts they have made in the last
year (appendix 9). Participants were then requested to abstain from smoking cigarettes
from 10pm that evening, and to attend a second session at 10am the next day to take
part in the actual intervention (after approximately 12 hours of abstinence). Once
overnight abstinence was established with an exhaled CO reading of < 10ppm, and the
exact length of abstinence was ascertained, participants were allocated to one of four
conditions based on a random number generated in advance of their arrival. The four
conditions were:
a) Active nicotine patch plus:
(i) Guided body scan
(ii) Control audio
b) Placebo nicotine patch plus:
(iii) Guided body scan
(iv) Control audio
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Participants were given a palmtop computer (PalmOne, Tungsten E2) to record their
baseline ratings for strength of desire to smoke and withdrawal symptoms using the
Mood and Physical Symptoms Scale (MPSS; West & Hajek, 2004), and administered
either an active or placebo nicotine patch by the researcher in accordance with their
allocated condition. Participants were blind to their allocated condition until
debriefing, and were informed that there was an equal chance of receiving an active
nicotine or placebo patch, and that they were unlikely to suffer any noticeable side
effects from either. They were then given an mp3 player (Mikomi FM6611 512mb)
containing the appropriate audio recording, which for the importance of consistency,
was made by the same person and edited to include approximately the same number
of pauses at the same time points. Finally, participants were asked not to consume
alcohol, take vigorous exercise or do anything beyond their normal routine whilst
participating in the study.
Once the participant left the laboratory, the palmtop computer sounded an alarm an
hour after the baseline ratings were given (approximately 11am), automatically turned
itself on, and prompt them to make another set of desire to smoke and withdrawal
symptom ratings. Once this was complete, they were to turn the palmtop off again and
continue with their normal routine. Two hours after the initial baseline ratings were
given (approximately 12pm), the palmtop sounded another alarm and turned itself
back on, and asked the participant to make a further set of MPSS ratings before
listening to the 10 minute audio recording on the mp3 player. Once this had finished,
the palmtop asked them to make further ratings immediately after the intervention,
and then again at 5, 10, 20 and 30 minutes following the intervention. Participants
105
were given an information sheet detailing the intervals at which the palmtop would
prompt them to make ratings and listen to the audio intervention (appendix 10):
Figure 4.1 Rating schedule for MPSS items immediately before and after audio intervention
On returning to the laboratory, participants were asked to complete a final
questionnaire regarding the perceived effectiveness of the intervention (appendix 11),
and then debriefed on their allocated condition. The palmtop computer and mp3
player were returned to the researcher, and once abstinence was confirmed with a
final CO reading of < 10ppm, participants were paid £10.00 for taking part, and were
free to take the active/placebo patch off and smoke again if they wished. The
researcher then pointed out the details of a number of useful quit support websites and
the free phone numbers of NHS local and national smoking helplines on the ratings
interval sheet, which was retained by participants.
Rating 1(Just before audio)
Rating 2 (Just after)
Rating 5 (20 mins after)
Rating 3(5 mins after)
Rating 6 (30 mins after)
Audio (10 mins)
Rating 4 (10 mins after)
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4.3 Results
4.3.1 Baseline comparisons
A series of one way analyses of variance (ANOVAs) were used to compare the
baseline characteristics of the four groups (body scan plus NRT, control audio plus
NRT, body scan plus placebo, and control audio plus placebo), and indicated that
there were no significant differences between the groups for any of the demographic
or smoking related characteristics: Age, F(3,68) = 0.66, p = .58 (ns); Cigarettes
smoked per day, F(3,68) = 1.19, p = .32 (ns); Years smoking, F(3,68) = 1.08, p = .37
(ns); FTND, F(3,68) = 0.97, p = .41 (ns); Post-abstinence ECO, F(3,68) = 0.75, p
= .52 (ns); Time since last cigarette, F(3,68) = 0.39, p = .76 (ns). The means and
standard deviation for each can be seen in table 4.1.
Table 4.1
Mean ± SD of demographic and smoking characteristics by group
NRT &
body scan
(n = 18)
Placebo &
body scan
(n = 18)
NRT &
control audio
(n = 18)
Placebo &
control audio
(n = 18)
Age 24.3 ± 6.1 27.7 ± 11.2 26.8 ± 10.4 28.7 ± 10.1
Cigarettes per day 12.3 ± 2.3 13.1 ± 3.2 14.2 ± 4.1 12.8 ± 2.7
Years smoking 7.7 ± 4.3 11.4 ± 10.2 11.1 ± 10.7 12.9 ± 9.6
FTND 3.7 ± 1.6 3.9 ± 1.5 4.2 ± 1.9 3.3. ± 1.5
Post-abstinence ECO 4.9 ± 2.0 4.1 ± 2.5 5.3 ± 2.9 4.5 ± 2.4
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Hours since last cigarette 12.4 ± 0.9 12.7 ± 1.6 12.8 ± 2.1 12.4 ± 0.8
FTND = Fagerström Test for Nicotine Dependence; ECO = Expired Carbon Monoxide
Chi-squared analysis indicated that there were also no significant differences between
the groups for: marital status, χ2 = 11.39, df = 12, p = .49 (ns); occupation, χ2 = 13.04,
df = 15, p = .59 (ns); ethnicity χ2 = 24.99, df = 21, p = .25 (ns); desire to give up, χ2 =
1.16, df = 3, p = .76 (ns). There was however a significant difference in the gender
ratios between the groups; χ2 = 7.80, df = 3, p < 0.05, with significantly more males in
the NRT plus body scan group, and significantly more females in the placebo plus
control audio group. As a result and where necessary, gender was entered as a
covariate during data analysis to control for any potentially confounding effects. The
percentage split for each factor for each group can be seen in table 4.2.
Table 4.2
Percentages for gender, marital status, occupation, ethnicity & desire to give up
smoking by group
NRT &
body scan
(n = 18)
Placebo &
body scan
(n = 18)
NRT &
control audio
(n = 18)
Placebo &
control audio
(n = 18)
Men 72.2* 50.0 61.1 27.8*
Single 77.8 77.8 72.2 77.8
Married 5.6 5.6 11.1 22.2
Professional/Manager 27.8 27.8 33.3 33.3
Student 66.7 50.0 66.7 50.0
Caucasian 94.4 77.8 83.3 88.9
Want to give up smoking 66.7 72.2 66.7 55.6
* Percentage difference is significant at the .05 level
A further series of one way ANOVAs were used to compare the 10.00am baseline
levels of strength of desire to smoke and six withdrawal symptoms measured by the
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MPSS for the four groups before they were allocated to a patch condition: Strength of
desire to smoke; F(3,68) = 0.32, (ns); Irritability, F(3,68) = 0.20 (ns); Tension, F(3,68)
= 2.64 (ns); Restlessness, F(3,68) = 1.40 (ns); Difficulty concentrating, F(3,68) = 2.32
(ns); Stress, F(3,68) = 1.33 (ns); Depression, F(3,68) = 2.77, p < .05. Post-hoc
analysis indicated that there was a significant difference in baseline depression ratings
given by the NRT plus body scan group and placebo plus control audio group,
however because depression had a low baseline rating across all four groups, it was
excluded from any further analysis. The means and standard deviations for each item
by group can be seen in table 4.3.
Table 4.3.
Mean ± SD of desire to smoke and MPSS withdrawal items by group
NRT &
Body scan
(n = 18)
Placebo &
Body scan
(n = 18)
NRT &
Control
(n = 18)
Placebo &
Control
(n = 18)
Strength of desire to smoke 4.61 ± 1.54 4.78 ± 1.40 5.06 ± 1.47 4.67 ± 1.53
Irritability 3.56 ± 1.75 3.72 ± 1.56 3.50 ± 1.76 3.28 ± 1.87
Depression 2.78 ± 1.83* 2.50 ± 1.34 2.50 ± 1.34 1.56 ± 0.70*
Tension 4.00 ± 1.61 3.56 ± 1.42 4.06 ± 1.59 2.83 ± 1.25
Restlessness 4.11 ± 1.41 3.94 ± 1.30 4.39 ± 1.72 3.33 ± 1.91
Difficulty Concentrating 3.56 ± 1.58 3.33 ± 1.57 4.06 ± 1.47 2.67 ± 1.78
Stress 3.39 ± 1.79 3.50 ± 1.65 3.67 ± 1.68 2.67 ± 1.33
* Mean difference is significant at the .05 level
In terms of baseline correlations, those who scored higher on the FTND also gave
higher baseline rating for strength of desire to smoke (r = .49, p < 0.001), irritability (r
= .52, p < 0.001), tension (r = .54, p < 0.001), restlessness (r = .48, p < 0.001),
difficulty concentrating (r = .52, p < 0.001) and stress (r = .47, p < 0.001). This is in
line with expectation, as the higher an individual’s level of nicotine dependence, the
109
higher their desire to smoke and withdrawal symptoms would be in response to an
acute period of abstinence. Additionally, there were significant correlations between
all baseline MPSS ratings and the number of cigarettes a person reported smoking per
day: strength of desire to smoke (r = .21, p < 0.05), irritability (r = .31, p < 0.01),
tension (r = .34, p < 0.01), restlessness (r = .28, p < 0.01), difficulty concentrating (r =
.35, p < 0.01) and stress (r = .32, p < 0.01). There were no significant correlations
between any of the MPSS baseline ratings and age, post-abstinence ECO, years
smoking or hours of abstinence.
4.3.2 Data screening
Data screening was conducted in order to highlight any participants who reported a
very low desire to smoke at baseline. In other words, those who reported their desire
for a cigarette at 10.00am as either 1 (not at all) or 2 (slightly) were excluded from the
dataset. This excluded six participants: two from the NRT plus body scan group, one
from the placebo plus body scan group, one from the NRT plus control audio group,
and two from the placebo plus control audio group. Furthermore, reliability analysis
of the five remaining MPSS items showed high inter-item correlations and a high
level of internal consistency, α = .90, so for all further analyses they were grouped
together and treated as a single item labelled ‘withdrawal symptoms’.
4.3.3 Changes in desire to smoke and withdrawal symptoms pre-audio intervention
Plasma concentrations of nicotine (i.e. changes in blood levels and tissue distribution
of nicotine) reach a plateau within 2 hours of initial patch application (Berner & John,
1994), meaning that participants should have been receiving optimum relief from
nicotine cravings and withdrawal symptoms at this point. A preliminary analysis
between the NRT and placebo patch conditions was therefore conducted looking at
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the change in ratings of desire to smoke in the two-hour time period following patch
application but prior to the audio intervention. As per the method used by Cropley et
al (2007), for both desire to smoke and composite withdrawal symptoms, 10am
baseline ratings were subtracted from ratings given at 11.00am and 12.00pm, and the
change scores analysed using a series of group (NRT & placebo) by time (11.00am &
12.00pm) repeated-measures analysis of variance (ANOVA). The results indicated
that there was no significant main effect of patch condition F(1,64) = 3.43, p = .07
(ns), or time F(1,63) = 0.01, p = .92 (ns), and is contrary to expectations as it suggests
that neither patch type had a significant impact on ratings of desire to smoke in the
two hours prior to the audio intervention. Furthermore, (albeit non-significant) the
placebo patch resulted in a greater reduction in desire to smoke than the NRT patch
(see figure 4.2).
11am 12pm
-1.10
-0.90
-0.70
-0.50
-0.30
-0.10
0.10
0.30
0.50NRT
Placebo
Mea
n ch
ange
in d
esire
to sm
oke
Figure 4.2 Changes in pre-audio intervention ratings of desire to smoke by patch
The same analysis was then conducted looking at changes in withdrawal symptom
ratings in the two hours prior to taking part in the audio intervention (but after
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receiving a patch), between those wearing an NRT and a placebo patch. The results
indicated that again there was no significant main effect of group F(1,64) = 1.06, p
= .31 (ns) or time F(1,64) = 0.01, p = .92 (ns), and contrary to expectations suggests
that neither the nicotine or placebo patch had a significant impact on withdrawal
symptom ratings prior to the audio intervention. Furthermore, mean ratings of
withdrawal symptoms actually increased in the NRT group after receiving the
nicotine patch (see figure 4.3).
11am 12pm
-0.20
-0.15
-0.10
-0.05
0.00
0.05
0.10
0.15
0.20
0.25
0.30NRT
Placebo
Mea
n ch
ange
in w
ithdr
awal
sym
ptom
s
Figure 4.3 Change in pre-audio intervention ratings for withdrawal symptoms by patch
To summarise, there does not appear to be any significant difference in ratings of
desire to smoke or tobacco withdrawal symptoms between those wearing an active
NRT or placebo patch. This suggests that the groups were relatively equal in terms of
the reported levels of craving and withdrawal symptoms prior to receiving the audio
intervention two hours after the patches were initially applied.
4.3.4 Changes in desire to smoke and withdrawal symptoms post-audio intervention
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Again, for both desire to smoke and composite withdrawal symptoms, pre-audio
baseline ratings were subtracted from ratings given immediately after the
interventions and at 10, 20 and 30-minutes post-intervention. This change score data
was analysed using a series of group (NRT & body scan / NRT & placebo / placebo &
body scan / placebo & control) by time (0, 10, 20, 30 minutes post-intervention)
repeated-measures ANOVAs. Due to the significant difference in the male to female
ratio between two of the groups (NRT plus body scan and placebo plus control audio),
gender was also used as a covariate to control for any potentially confounding effects.
The results indicated that for ratings of desire to smoke, while there was no significant
interaction effect F(9,186) = 1.37, p = .21 (ns) or main effect for group F(3,62) = 1.75,
p = .17 (ns), there was a significant main effect of time F(3,186) = 1.63, p < .01, ηp2
= .09. This suggests that irrespective of intervention type, there was a significant
change in ratings of desire to smoke over the course of the time points measured.
Furthermore, post-hoc analysis confirmed that the mean strength of desire to smoke
rating was significantly reduced both immediately (t = 3.99, df = 71, p < .001) and at
10-minutes post-intervention (t = 3.14, df = 71, p < .01). There were no significant
reductions after this point (see figure 4.4), however it does give an indication of the
duration of the intervention’s efficacy.
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0 mins 10 mins 20 mins 30 mins
-1.20
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40
0.60 NRT & body scan
Placebo & body scan
NRT & control
Placebo & control
Mea
n ch
ange
in d
esire
to sm
oke
Figure 4.4 Mean changes in desire to smoke ratings by group
The same analysis was then conducted for the composite rating of tobacco withdrawal
symptoms, with the results again indicating that while there was no significant
interaction effect F(9,186) = 1.92, p = .06 (ns), or main effect of group F(3,62) = 0.24,
p = . 87 (ns), there was a significant main effect of time F(3,186) = 4.69, p < .01, ηp2 =
.09. This again suggests that irrespective of intervention type, there was a significant
change in ratings of withdrawal symptoms over the course of the time points
measured. Post-hoc analysis further confirmed that relative to baseline ratings, the
mean withdrawal symptom rating was significantly reduced at all time points:
immediately (t = 5.07, df = 71, p < .001), 10-minutes post-intervention (t = 3.54, df =
71, p < .01), 20-minutes (t = 2.68, df = 71, p < .01), and 30-minutes (t = 2.92, df = 71,
p < .01). Figure 4.5 shows how ratings remain below baseline levels throughout the
experiment, and indicate that the interventions were still effective in reducing
withdrawal symptoms up to 30 minutes after the audio listening task.
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0 mins 10 mins 20 mins 30 mins
-1.10
-0.90
-0.70
-0.50
-0.30
-0.10
0.10
0.30
0.50 NRT & body scanPlacebo & body scanNRT & controlPlacebo & control
Mea
n ch
ange
in w
ithdr
awal
sym
ptom
s
Figure 4.5 Mean changes in withdrawal symptom ratings by group
To summarise, while there was no significant difference between baseline and post-
intervention desire to smoke or tobacco withdrawal symptoms rating according to
experimental group, there was an overall effect of the interventions over time. This
suggests that irrespective of patch type or audio task, the intervention had a significant
impact on ratings. This does however lead to the rejection of the hypothesis that there
would be a synergy between the NRT patch and body scan intervention, as there was
no significant difference between the ratings given for this group compared with the
other groups.
4.3.5 Credibility of interventions
If audio interventions combined with pharmaceuticals (NRT) are realistically to be
used as an aid to quitting smoking, it is important to explore how the participants in
this study perceived them. In light of this, measures of perceived credibility were
added in order to determine how useful and effective participants believed the
interventions to be, and whether they would recommend them as a strategy to others.
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Analysis indicated that in terms of usefulness, the two body scan conditions were
rated as most useful: NRT plus body scan (M = 2.83, SD = 1.15); Placebo plus body
scan (M = 2.83, SD = 1.04), followed by NRT plus control (M = 2.44, SD = 1.29) and
then placebo plus control (M = 2.28, SD = 1.18). As for recommending the
interventions to other smokers trying to quit, the two body scan conditions again were
rated highest; Placebo plus body scan (M = 3.28, SD = 1.07); NRT plus body scan (M
= 3.22, SD = 1.06), followed by NRT plus control (M = 2.83, SD = 1.47) and then
placebo plus control (M = 2.50, SD = 1.10). The final question asked how effective
interventions would be for most smokers, and again the two body scan conditions
were rated highest; Placebo plus body scan (M = 2.89, SD = 0.76); NRT plus body
scan (M = 2.61, SD = 1.14), followed by NRT plus control (M = 2.28, SD = 1.13) and
then placebo plus control (M = 2.17, SD = 1.04). This suggests that the body scan
interventions were rated as more credible than the control audio interventions,
however mean ratings only actually translated as “Slightly” or “Moderately” useful.
Despite this, ANOVAs were performed in order to compare the four conditions for
any significant differences in credibility rating, with the results unsurprisingly
indicating that there was no significant difference in how useful participants found the
interventions for relieving their desire to smoke (F (3,68) = 1.04, p = .38, ns),
recommending the interventions to other smokers (F (3,68) = 1.69, p = .18, ns), or
how effective they the interventions would be for most smokers (F (3,68) = 1.83, p
= .15, ns).
4.4 Discussion
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This study found that contrary to the hypothesis that there would be a synergistic
effect of combining NRT and a guided body scan on desire to smoke and withdrawal
symptoms, there was no significant difference between any of the groups across the
course of the time points measured. One potentially confounding factor that may have
affected the significance of the results was that despite the process of randomisation,
there was a significant difference in gender ratio between two of the groups. This is
especially noteworthy in light of research examining gender differences in the placebo
response during smoking cessation trials using Bupropion by Collins, Wileyto,
Patterson, Rukstalis, Audrain-McGovern, Kaufmann, Pinto, Hawk, Niaura, Epstein
and Lerman (2004). They found that while women had comparable abstinence rates to
men whilst using Bupropion, they tended to respond more poorly than men to
placebo. In the current study, there were significantly more women than men in the
placebo plus control arm of the study, and this may have resulted in a skewed
response to the placebo intervention in this group.
Irrespective of a potential gender effect, according to a review by Perkins, Sayette,
Conklin and Caggiula (2002), several important factors are thought to influence the
strength of the placebo effect in nicotine and tobacco based studies. Proximal
environmental stimuli in the form of salient cues or verbal instructions concerning the
drug content (or effect) determine the participant’s stimulus expectancy, and this
consequently elicits a pre-existing response expectancy regarding the likely effects of
consumption. In other words, if participants are given a placebo patch but receive
relevant instructions along with salient cues that they are wearing a nicotine patch,
this should prompt a stimulus expectancy in which they believe they are receiving
nicotine. This activates their response expectancy about the effect nicotine is likely to
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have on them thereby producing a placebo effect, i.e. reduced cravings and
withdrawal symptoms in the absence of nicotine replacement. The opposite
phenomenon, the anti-placebo effect, occurs when participants are given a nicotine
patch with instructions to the contrary, with the resulting stimulus expectancy that
they believe they are not receiving nicotine. Their response expectancies regarding the
effects an inactive patch would have on them (no effect), can reduce or prevent
normal responses to receiving nicotine, i.e. no reduction in cravings and withdrawal
symptoms (see figure 4.6).
Environmental stimuli
Subjects belief about drug content
Subject beliefs about drug effects Response
Salient cues Stimulus Response Placebo orexpectancy expectancy antiplacebo effects
Instructional set
Figure 4.6 Non-pharmacological influences on responses to substance use (Perkins et al, 2002)
According to Dar, Stronguin and Etter (2005) however, a balanced placebo design
makes the assumption that instructions fully control participants’ beliefs about their
assigned drug condition, and without verification of this assumption, the validity of
the design is at risk. This is especially a problem in studies using NRT due to the
easily recognisable effects of nicotine that cannot be accurately reproduced by a
placebo, and limits the ability to fully assess the placebo effect of NRT products.
Whilst every effort was made to maintain participant naivety in the current study by
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informing them of their equal chance of being allocated to either patch condition and
that there should be no noticeable side effects, participants were not formally asked
prior to taking part whether they had used NRT patches before. Having previous
experience of using NRT patches may have had an effect on participants’ response
expectancy, and as a result may be responsible for the antiplacebo response in the
experimental arm of the study.
Despite not being expected, and contrary to the findings of a number of existing
studies comparing NRT and placebo (e.g. Tonnesen, Norregaard, Simonsen & Säwe,
1991; Shiffman, Khayrallah & Nowak, 2000; Shiffman, Ferguson, Gwaltney,
Balabanis & Shadel, 2006), the results from the current study have nevertheless been
supported in previous research. For example, a study by Teneggi, Tiffany, Squassante,
Milleri, Ziviani and Bye (2002) compared free smoking with NRT and a placebo, and
report that while withdrawal symptoms were significantly lower for those in the free
smoking group compared to either the NRT or placebo, there was no difference in the
withdrawal symptom levels between those on the NRT patches and placebos. A
review by Dar & Frenk (2004) looking at self-administration of pure nicotine also
found that neither smokers nor non-smokers showed a preference for nicotine over
placebo in any of the studies reviewed. This casts doubt onto the widely held belief
that nicotine is the primary agent motivating tobacco smoking, and the main obstacle
facing smokers during a quit attempt. These studies suggest that traditional NRT fails
to moderate the non-pharmaceutical factors that maintain the negative consequences
of tobacco abstinence, and it is possible that when these factors were combined with
expectations associated with a placebo effect in the current study, any positive impact
of the nicotine replacement therapy was negated.
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In terms of exploring the therapeutic benefits of the guided body scan, the results of
the current study found that while there were no differences in efficacy between the
body scan and control audio on desire to smoke or withdrawal symptoms (irrespective
of patch condition), there were differences in the ratings given for both interventions
over time. This suggests that irrespective of audio intervention type, both had an
impact on ratings over the course of the study. Previous research using the same audio
interventions by Cropley, Ussher and Charitou (2007) and Ussher et al (2009) both
found that the guided body scan produced significantly lower ratings of desire to
smoke and some MPSS withdrawal symptoms compared to the control audio.
However, the effect was shown to diminish outside of a laboratory environment in the
Ussher et al (2009) study, and as participants in the current study also used the audio
intervention in their normal (non-lab) environment, uncontrolled environmental
factors may have contributed to their level of engagement with the body scan
instructions and consequently lessened it’s impact. Nevertheless, the results show that
both audio interventions had a significant impact on desire to smoke and withdrawal
symptoms, and prompts the need to explore why this result has occurred.
Despite the difference in content between the audio files, the common factor shared
by both is that the ‘intervention’ consisted of listening to a 10-minute audio delivered
experience. One potential theory is that they both functioned as a cognitive distractor
from cravings and withdrawal symptoms, and the act of simply ‘taking their mind off’
the negative consequences of tobacco abstinence was enough to temporarily reduce
ratings. The idea of using distraction tasks in the reduction of cravings and withdrawal
symptoms does not appear to have been well tested in the field of tobacco addiction,
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with literature searches returning only two studies looking directly at distraction as a
strategy for supressing cravings for a cigarette: following smoking cue exposure,
participants in a study by Versland and Rosenberg (2007) were randomly assigned to
listen one of three beach themed imagery interventions (olfactory, visual, olfactory
plus visual) or a distracting cognitive task (serial 7’s) and rate their craving levels.
They found that cravings during the intervention were significantly lower in all three
imagery conditions compared to the distraction task, and suggest that this type of task
holds the ability to interrupt cue induced cravings – even if temporarily. A later study
by May, Andrade, Panabokke and Kavanagh (2010) asked abstinent and non-abstinent
participants to create either auditory or visual mental images based on cues such as ‘a
telephone ringing’ (auditory) or ‘cows grazing’ (visual) and rate their craving strength
and mood before and after. They found that while the visual imagery task reduced
cravings in the abstinent smoker the auditory task did not, and argue that visual
imagery supports tobacco cravings, and that competing tasks reduce cravings by
loading the limited-capacity working memory. Building on this limited research, and
as a result of the findings of the current study, the theory that the guided body scan is
simply an effective form of cognitive distraction is explored and tested in the next two
chapters of this thesis.
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CHAPTER 5
STUDY 2: THEORIES OF COGNITIVE DISTRACTION & SEARCH FOR
BODY SCAN COMPARABLE DISTRACTOR TASKS
5.1 Introduction
Study three (chapter six) of this thesis aims to test whether the guided body scan
reduces cigarette cravings and nicotine withdrawal symptoms by acting as a form of
cognitive distraction during tobacco abstinence. As described in chapter four
however, literature searches returned very few studies on the subject of cigarette
cravings and distraction, with much of the cognitive focused research viewing
distraction as a negative consequence of attentional selection bias rather than a
potential coping strategy (e.g. Mogg, Bradley, Field & De Houwer, 2003; Waters,
Shiffman, Sayette, Paty, Gwaltney & Balabanis, 2003; Luijten, Veltman, van den
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Brink, Hester, Field, Smits & Franken, 2011). What follows is an exploration of
current theories of attention and distraction in relation to the management of tobacco
craving episodes, and a systematic literature search for suitable distraction strategies
to compare to the guided body scan in study three.
An early definition by James (1890) describes attention as: "the taking possession by
the mind, in clear and vivid form, of one out of what seem several simultaneously
possible objects or trains of thought… for at that moment, what we attend to is
reality" (p. 403). Which train of thought is attended to however, is affected by a
variety of different influences, with Baddeley and Hitch’s (1974) model of working
memory (WM) providing the foundation for many theories relating to information
storage and multi-task processing. At its very basic level, the model consists of the
central executive, which is responsible for coordinating information from the two
slave systems: the phonological loop, which stores verbal and auditory content, and
the visuo-spatial sketchpad, which processes visuo-spatial data. The processing of
incoming information by the central executive is however determined by the
application of selective attention, which is characterised as the mind’s ability to focus
cognitive resources on task relevant goals (Gazzaley & Nobre, 2012), but which is
also susceptible to disruption and bias from a variety of sources.
For example, Lavie’s (1995) load theory of attention argues that perceptual load is a
central causal factor in determining the efficiency of selective attention, and that
perceptual load during task-relevant processing automatically influences the
likelihood of task-irrelevant information being processed – resulting in distraction. He
reports a series of experiments examining response times during target item
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identification tasks under conditions of high and low perceptual load, such as
manipulating the number of items amongst which the target item appears, or the form
and colour of both target and distractor items. The results showed that task
interference was only seen under conditions of low perceptual load and was
eliminated under conditions of high perceptual load. He argues that tasks involving
high perceptual load leave no capacity for distraction by task-irrelevant information,
whereas during tasks involving low perceptual load, spare capacity remaining beyond
task relevant processing allows for the involuntary intrusion of distractor processing
(Lavie, 2010). This suggests that in order for distraction to be actively used as a
coping strategy during a craving episode, the task must involve a higher perceptual
load than that of the craving process.
This idea is supported by McCaul and Malott (1984), who conducted a literature
review looking at the use of distraction in the management of pain-produced distress.
They discuss how understanding the distinction between controlled and automatic
processing during task performance has important implication in determining the
efficacy of a distraction task for two reasons. Firstly, for distraction to be effective,
pain perception must be assumed to be a controlled process because if it was
automatic, processing and response mechanisms would occur without drawing on
attentional resources, and distraction would be ineffective. This fits well with the
cognitive processing model of tobacco urges (Tiffany, 1999), which maintains that
while habitual smoking is an automatic process that (mostly) occurs without any
effort or conscious awareness, craving is a non-automatic cognitive process that
occurs in response to obstacles blocking the automatised smoking behaviour, and
consequently requires cognitive effort and attentional awareness.
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Secondly, the distraction task itself must also involve controlled rather than automatic
processing, as it must utilise sufficient attentional resources in order to limit the
capacity for the controlled processing of pain perception. The findings of the 29
studies reviewed by McCaul and Malott (1984) support these assumptions, and lead
the authors to conclude that the more a distraction task requires controlled cognitive
processing, the less cognitive resources are available to process the pain sensations,
and therefore an engaging distraction task will be more successful at reducing pain
than a passive task. This may also explain how performing a guided body scan can
reduce cigarette cravings (e.g. Cropley, Ussher & Charitou, 2007; Ussher et al, 2009),
as the process of following the audio delivered instructions to shift the focus of
attention between different body parts arguably involves controlled rather than
automatic processing, and may therefore leave less cognitive capacity for the craving
process.
The distraction process may not however be as straightforward as simple competition
for cognitive capacity, as a further factor to take into account is that different types of
working memory load have different effects on selective attention depending on
whether there is any task relevant overlap in the sensory modalities involved in target
and distractor processing (Kim, Kim & Chun, 2005). This is in line with the multiple
resource theory of attention by Wickens (2002), which was developed on the basis
that effective multitasking is possible without a decline in performance depending on
the types of task being performed, because not all tasks complete for a “single
undifferentiated “pool” of demand-sensitive resources” (p. 449). It proposes the
existence of multiple attentional resources that act relatively independently, such that
engaging in a task using one form of sensory input (e.g. reading) may not necessarily
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interfere with other sensory modalities (e.g. listening to music). Conversely, when
dual-tasks compete for the same modalities, interference can result in a detriment to
performance in terms of increased reaction times and error rates. For example, a study
by Duncan, Martens and Ward (1997) examined the impact of within and between
modality processing by presenting participants with streams of visual and/or auditory
inputs and asking them to identify and recall occasional targets. When two visual or
two auditory streams were presented, there was significant interference in participant
ability to identify the second of two (same modality) targets because their attention
was assigned to the first target and therefore unavailable to attend to the second. This
interference was not seen when participants were presented with different modality
targets, and suggests that while visual attention does not interfere with concurrent
auditory attention, there are modality specific restrictions during concurrent within
modality task processing. This suggests that a successful distraction task would
require not only a comparable or higher perceptual load than the attention devoted to
the experience of craving, and to draw upon controlled (rather than automatic)
cognitive processes, but that it must also utilise the same sensory modalities as the
craving process in order to effectively disrupt it.
These are the theories behind the few studies that have explored the use of distraction
in the management of addiction-based cravings. For example an early case study
report by Bradley and Moorey (1988) explored the use of distraction in reducing
cravings during exposure to drug related cues in an individual suffering from heroin
addiction. They asked the participant to repeatedly recite a nursery rhyme during drug
cue exposure and found that compared with three previous cue exposure trials that
resulted in increased cravings, utilising a distraction task resulted in a notable
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decrease in cravings during the task, although levels increased again once the task was
discontinued. They suggest that the distraction task reduced cravings by negating both
drug related thoughts, and attention to drug related cues by competing for the limited
attentional resources available.
Stemming from the treatment of food addiction, this idea is further explored by
Kavanagh and colleagues with their Elaborated Intrusion (EI) theory of desire (May et
al, 2004; Kavanagh et al, 2004; 2005). As described in chapter one, EI theory
discusses the cognitive and emotional processes that occur during desire, with mental
imagery and its link to affective content playing a central role in whether the urge for
a substance is elaborated upon and followed through. According to the theory,
cravings, which are defined as intense desires, are triggered both by external cues
(e.g. seeing somebody else smoking) as well as internal cues (e.g. a drop in blood
plasma concentrations of nicotine), and associated thoughts and affective states
(including boredom). These triggers lead to an initial intrusive thought that forces it’s
way into the individual’s field of attention, and if elaborated upon, creates a craving
episode and a conscious decision to acquire the desired target (e.g. a cigarette). They
argue that while elaboration may be semantic in nature, or focus on physiological
sensations such as withdrawal symptoms, the cognitive core of cravings are
emotionally charged sensory images that simulate the experience of acquiring and
consuming the addictive substance (May, Kavanagh & Andrade, 2015). This imagery
is important because it transmits the pleasure of partaking in the ‘real thing’ whilst at
the same time making the individual acutely aware of the disparity between their
current and desired state. Desire imagery is therefore both briefly pleasurable but
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ultimately aversive if the desire is not fulfilled, and consequently fuels a negative
emotional state that further motivates the substance seeking behaviour.
Based on the work of Baddeley and Andrade (2000), Kavanagh et al (2005) discuss
how the generation, maintenance and manipulation of these vivid images relies on
several high-level cognitive processes. Elements of an image, including sensory
information (e.g., the smell of cigarette smoke), generic characteristics (e.g. the form
of the cigarette packet), and specific episodes (e.g. how good the first cigarette of the
day felt), are retrieved from long-term memory. Central executive functions control
this retrieval process, with additional relevant information also being available from
the immediate environment and stored in appropriate subsystems of working memory.
For example, the visuo-spatial sketchpad and phonological loop serve as workspaces
for storing the retrieved information, with the “manipulation of this information, by
modality-specific rehearsal processes and amodal central executive processes,
contributing to the experience of vivid, quasi-lifelike images” (p. 450).
Evidence that the vividness of craving related images can be reduced by concurrent
tasks which require the switching of attention to competing visuo-spatial information
is presented in a study by May, Andrade, Panabokke and Kavanagh (2010). They
asked abstinent and non-abstinent smokers to create either auditory or visual mental
images based on cues such as ‘a telephone ringing’ (auditory) or ‘cows grazing’
(visual) and rate their craving strength and mood before and after the imagery task.
They found that while the visual imagery task reduced cravings in the abstinent
smoker the auditory task did not, and argue that visual imagery supports tobacco
cravings, and that competing tasks reduce cravings by loading the limited-capacity
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working memory. In terms of the guided body scan, May et al (2012) report that a 10-
minute body scan routine significantly reduced cravings and craving related thoughts
in temporarily abstinent smokers during the experimental period compared with mind
wandering instructions. The authors do not propose any mechanisms by which the
effect is occurring, however the body scan is an audio delivered intervention with no
direct visual imagery instructions, and this suggests that the craving process does not
rely wholly on visual imagery, but that the loading of working memory with task-
irrelevant audio content can also serve as an effective disruption to intrusive thoughts.
A study by Versland and Roseberg (2007) also looked at the impact of three types of
‘beach themed’ imagery interventions (olfactory, visual and olfactory-plus-visual
imagery) and a distracting cognitive task (serial sevens) on cigarette craving levels
during a cue exposure trial. They assessed smoking urges before and after 2 minutes
of cue exposure, during the 2-minute imagery or distraction intervention, and
immediately following the intervention, and found that there was a significant
reduction in self-reported cravings during all three imagery interventions compared
with the distraction task. One issue with using the serial 7’s task as a cognitive
distraction exercise however is that it is also used as a stress induction test (e.g. Burg,
Jain, Soufer, Kerns & Zaret, 1993; Dedovic, D’Aguiar & Pruessner, 2009), and raised
stress levels could be negating any positive effect of distraction. Furthermore,
increased stress may actually exacerbate cigarette cravings (e.g. Perkins & Grobe,
1992; Childs & De Wit, 2010), and this highlights the importance of assessing any
potential undesirable side effects in the design of effective distraction interventions.
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To summarise, based upon the theories of attention and working memory processes
presented, the guided body scan may indeed perform the function of distracting
smokers from craving related thoughts by engaging higher-level cognitive processes
that compete for limited attentional resources. More specifically, it could be argued to
involve a perceptual load that is greater than that of craving focused ruminations,
controlled rather than automatic processing, and employ competing sensory
modalities. In order to empirically test this theory, the final study aims to compare the
effect of the guided body scan to other distraction tasks involving both active and
passive attention, and differing sensory modalities, on tobacco cravings and
withdrawal symptoms. As discussed previously however, there is a lack of existing
literature looking specifically at distraction strategies for smoking cravings, and even
when the search criteria was widened to include all fields of research using distraction
as a cognitive intervention, it was clear that there were no ‘validated’ distraction tasks
per se, but rather cognitive tasks had either been chosen or designed for the specific
purposes of each individual study. The aim of the current study is therefore to:
1. Explore how participants rate different types of distraction tasks on measures
of attention, difficulty, relaxation and enjoyment.
2. Ascertain which tasks are rated as most closely resembling the guided body
scan technique on the above measures.
5.2 Methodology
5.2.1 Systematic search
Due to the absence of validated cognitive distraction tasks to use as a comparison to
the guided body scan in study three, a wide systematic literature search was conducted
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to identify previous psychological and medical studies that have utilised any kind of
distraction strategy. Electronic databases that were searched included the Cochrane
Library Database, PsychInfo (1970 – 2014), Medline (1966 – 2014) and EMBASE
(1988 – 2014) using the search terms distraction, cognitive distraction and distract$.
The symbol $ was used at the end of search terms to represent truncation and allow all
variations of the word to be elicited. A general Internet search was also conducted
using the Google Scholar search engine. Searches were completed in September 2014.
The resulting studies from the systematic search were then screened via the abstract
for suitability of inclusion, and the following characteristics of each study are detailed
fully in a summary grid (appendix 13): Author(s), year of publication, article title and
source, number of participants, type of cohort (e.g. adult, child, clinical population),
task and task classification. Due to the lack of an existing framework and the vast
heterogeneity in the types of tasks identified, to enable the grouping of similar tasks
into a coherent structure, classification was designated in a relatively subjective
manner. For example, whilst some of the tasks were purely visual (e.g. a screen based
shape identification task; Moont, Pud, Sprecher, Sharvit & Yarnitsky, 2010), or purely
auditory (e.g. a tone detection task; Verhoeven, Goubert, Jaaniste, Van Ryckeghem &
Crombez, 2012) many utilised a combination of both sensory modalities (e.g. virtual
reality games; Law, 2012; watching film extracts; Bartgis, Thomas, Lefler & Hartung,
2007), and others were even harder to classify as they only involved internal cognitive
processes such as long term memory (e.g. being asked to recall high school teachers’
names; Ahles, Blanchard & Leventhal, 1983), mental imagery (e.g. being asked to
imagine a pleasant scene; Kohl, Rief & Glombiewski, 2013) or thought suppression
(e.g. instructions to suppress drug related thoughts in addicts; Reynolds, Valmana,
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Kouimtsidis, Donaldson & Ghodse, 2005). It may be the case that the internal
cognitive tasks also utilised a combination of sensory modalities, but without
individual data it is not possible to definitively categorise them as either. In light of
this, table 5.1 (overleaf) presents a breakdown of the 341 distraction tasks extracted
from the 308 academic papers in terms of both frequency and sensory modality.
Table 5.1
Summary of the number of distraction tasks per classification category 2
Task Classification Count
Visual TaskNumber Task 64General Visual Task 31Word Task 30Reading 12
Auditory TaskMusic 33General Auditory Task 8Story Listening 7Talking 5
Audio & VisualFilm 29Virtual Reality 29Game (electronic) 17Game (non-electronic) 15
2 See appendix 13 for full details of each study with references.
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CognitiveMental Imagery 48Memory Task 7Thought Suppression 6
Total 341
The five distraction tasks selected for use in the current exploratory study were
determined based on the most frequently occurring types of task in the literature (see
table 5.1), those that engaged differing levels of attention and sensory modalities, and
were feasible within the scope of this study. A full description and justification for
inclusion of each chosen task is presented below.
5.2.2 Distraction Tasks
Distraction task 1: Passive text listening
The passive text listening condition consisted of a 5-minute extract from the ‘Natural
History and Antiquities of Selborne’ (White, 1997; see chapter four for full details).
This was chosen for inclusion because it was described by participants in the Cropley
et al (2007) study as a neutral yet relaxing passage, and according to the theories of
attention and distraction discussed earlier, the passive nature of the task should
engage fewer high-level cognitive processes than the body scan and result in less
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distraction from craving related thoughts. The audio delivery, without imagery
instructions should call primarily on the phonological loop, although depending on
how engaged the listener is with the content, they may automatically create visual
images of the landscape features described.
Distraction task 2: Active audio book story listening
The active audio book listening task consisted of a five minute audio delivered extract
from The Hitchhiker's Guide to the Galaxy© read by Stephen Fry (Macmillan Digital
Audio, 2005). This was included because in contrast to the passive text listening
condition, as it is hypothesised that the listener will actively engage with the popular
and entertaining story narrative, and therefore find it a more cognitively distracting
task. It should primarily draw on the phonological loop, but again, despite the lack of
imagery instruction and depending on how engaged the listener is with the story,
visual imagery may also be utilised.
Distraction task 3: Classical music listening
The classical music condition consisted of participants listening to a five-minute
segment of the Sonata in D major for Two Pianos by W. A. Mozart, K 448 (Teldec:
4509-91378-2), with half of the segment being taken from the first movement
(Allegro conspirito) and half from the second (Andante). A combination of these two
segments was used previously by Scheufele (2000), and was chosen because of the
shift from a stimulative to a sedative melody, which has been found to be more
effective as a relaxation technique than sedative music alone (Rider, 1985). Classical
music has also been used successfully as a distraction task in previous studies in the
form of music analgesia (e.g. Villarreal et al, 2012; Kristjánsdóttir & Kristjánsdóttir,
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2011, & Silvestrini et al, 2011). It should engage the phonological loop, as there are
no imagery instructions or visual stimuli involved in the task.
Distraction task 4: Computer game playing
Participants played the computer game ‘Bejeweled HD’© (Electronic Arts Inc., 2014)
for five minutes on a tablet computer. The aim of the game was to create colour
matches of three or more jewels of the same colour. Various forms of electroinc
gaming were identified as being used as a distraction task in the literature search,
mostly for use as acute analgesia (e.g. Sil et al, 2014, 2013; Weiss et al, 2011;
Campbell et al, 2010), but also for reducing behavioural distress (Windich-Biermeier
et al, 2007; Schneider &Workman, 1999), reducing nausea, anxiety and systolic blood
pressure (Vasterling et al, 1993; Redd et al, 1987), and stress (Williams et al, 1990).
Furthernore, a study by Wohlheiter (2012) split game use into interactive game
playing, versus passive game watching distraction, with the results showing that
interactive distraction provided superior pain tolerance compared with passive
distraction. In light of this, the game task chosen for the current study is very simple
to learn and play, but requires full participant interaction and therefore places
moderate demand on central executive functioning. In contrast to the first three tasks
mentioned, it is primarily a visual task and should highly enagage the visuo-spatial
sketchpad and a high level of working memory capacity.
Distraction task 5: Mental arithmetic
After a one-minute practice, participants performed five minutes of the Paced Visual
Serial Addition Task (PVSAT, Fos et al, 2000). This task required participants to
monitor the presentation of single-digit numbers presented one per second on the
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screen, reporting out loud the sum of the last two numbers seen. It was used by Daniel
et al (2006) as a cognitive distraction task, and was chosen for the current study due to
the high demand it places on working memory and therefore the capacity it has to
limit the use of central executive functions to monitor other stimuli. Again it is a
visual task and should engage the visuo-spatial sketchpad.
The guided body scan
After receiving brief verbal instructions about what the guided body scan entailed,
participants were guided through a five-minute audio recording of a seated body scan
routine based on that used originally by Cropley et al (2007), and detailed fully in
chapter four. As an audio delivered intervention, the body scan primarily engages the
phonological loop.
5.2.3 Participants
Opportunity sampling was used to select the participants for the present investigation,
who were recruited via e-mail and posters advertising the study placed around the
University of Surrey campus and offices in Maidenhead (appendix 14). G-power
calculation indicated that a sample size of 36 participants was needed for a power of
95% (Cohen, 1988), with a significance level of .05 and an effect size of .30. The
sample consisted of 18 male and 18 female participants, aged between 21 and 65
years (M = 36.8, SD = 12.2). In terms of ethnicity, 89% were White, 8% were Indian
and 3% were White and Asian. Professional/managers accounted for 44% of the
sample, 36% were clerical/secretarial, 11% were homemakers, 6% skilled manual and
3% were students. Participants were not compensated for their participation in any
way.
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5.2.4 Design
The study employed a within subjects design, whereby 36 participants took part in the
six tasks in a random order generated in advance of their arrival for testing via a
computer based random number generator. The independent variable was the type of
distraction task, and the dependent variable was the responses to a questionnaire
asking them how the task made them feel.
5.2.5 Measures
Distraction Task Questionnaire
In the absence of a pre-existing psychometrically validated measure of distraction, a
13-item questionnaire was designed for the purposes of the current study in order
explore how the different types of task made participants feel in terms of attention
expenditure, difficulty level, relaxation and enjoyment (appendix 15). Participants
completed the questionnaire after performing each of the tasks by making ratings on a
7 point Likert type scale ranging from 1 = ‘not at all”, to 7 = ‘extremely’. Exploratory
factor analysis was not conducted due to a small sample size not meeting the ideal
participant to item ratio of 10:1 (Osborne & Costello, 2009), however reliability
analysis is reported for each group of items:
1) Attention expenditure: attention, distraction, mind wandering, consciousness
and boredom. This was included to explore the potential impact of each type
of task on competition for cognitive capacity, and resulted in a Cronbach’s α
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for the five items of 0.70, indicating an acceptable level of internal
consistency.
2) Task difficulty: difficulty, challenge, pressure and stress. This was included
because while expenditure of attention may be the central factor in
determining the efficacy of a distraction task, high levels of task difficulty
could also lead to stress. The Cronbach’s α for the four items was 0.81,
indicating a good level of internal consistency.
3) Relaxation: relaxing and calming. This was included to explore the theory
tentatively proposed by Ussher et al (2006), that the reductions in cravings
observed after a body scan intervention may be the result of a relaxation
response. If relaxation is a core element of the body scan, comparable
distraction strategies would ideally also involve a relaxation factor. The two
items produced a modest Cronbach’s α of 0.66.
4) Fatigue. The item was excluded from analyses as it did not fit well with any of
the other items on the questionnaire, had very low power during initial
analysis (ηp2 = .12), and when completing the questionnaire many participants
were not sure how to answer the question in relation to the tasks.
5) Enjoyment. This single item question was included as a basic measure of task
preference.
5.2.6 Procedure
Upon expressing interest in taking part in the study, participants were screened to
check their eligibility status by confirming that they were within the correct age range
and able to read and write in English. Once eligibility was established, participants
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were asked to present at the psychology lab, or meet at another convenient location
where they were given a participant information sheet to read (appendix 16), a
consent form to sign (appendix 17), and an opportunity to ask any questions. A
questionnaire was then completed to obtain demographic information such as age,
gender, ethnic group, occupation and level of study (appendix 18).
Participants performed the six tasks in a random order chosen via an Excel random
number generator in advance of their arrival. The six tasks were:
(i) The guided body scan
(ii) Passive text listening (Selborne extract)
(iii) Active audio book listening (Hitchhiker’s Guide©)
(iv) Classical music listening (Mozart)
(v) Electronic game playing (Bejewelled HD©)
(vi) Computer based mental arithmetic (PVSAT)
The audio files were pre-loaded onto a tablet computer (Apple™ iPad®), which
participants listened to through a set of individual earphones. The electronic game
was also played on the tablet in the form of a downloaded application (‘app’), and the
PVSAT was presented on a laptop computer in the form of a PowerPoint presentation.
Upon completion of each task, participants were given the post-task questionnaire
asking them the same 13 questions relating to how the task made them feel (appendix
13). Once each task was completed and rated, participants were thanked for their time
and were free to leave.
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5.3 Results
5.3.1 Comparison of task ratings on post-task questionnaire items
The first aim of the research was to explore how participants rated different types of
distraction tasks on measures of difficulty, attention, relaxation and enjoyment. Due to
the acceptable level of internal consistency for each scale of grouped questions, a
series of repeated measures ANOVAs was conducted to examine whether there were
any significant differences in the ratings given for each task on these composite
factors. Figures showing the results for individual items can however be found in
appendix 19.
Measures of attention requirement
For composite ratings of attention, the results showed that there was a significant
difference between the tasks: F(5, 175) = 39.03, p < .001, ηp2 = .53. Post-hoc analysis
with Bonferroni correction indicated that the Selborne extract (M = 3.37, SD = 1.13)
was rated as engaging significantly less attention than all other tasks, and the PVSAT
(M = 6.20, SD = .82) required significantly more attention than all other tasks.
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Body scan Selborne Audio book Classical music
Game PVSAT2.00
3.00
4.00
5.00
6.00
7.00M
ean
ratin
gs o
f atte
ntio
n
Figure 5.1. Mean rating of attention expenditure by task
Figure 5.1 shows that the tasks placing the highest demand on the central executive
and primarily engaged the visuo-spatial sketchpad (performing the PVSAT & playing
the electronic game) were rated as significantly more attention consuming than all of
the tasks that involved actively (guided body scan & audio book) or passively
(Selborne extract & classical music) listening to an audio file. The particularly low
rating given for the Selborne extract is in line with anecdotal participant feedback that
the vast majority found it very boring and hard to concentrate on.
Measures of task difficulty
For composite ratings of task difficulty, the results showed that there was a significant
difference between the tasks: F(3.70, 129.40) = 91.74, p < .001, ηp2 = .72 (using
Greenhouse-Geisser estimates of sphericity). Post-hoc analysis with Bonferroni
correction indicated that the PVSAT (M = 5.45, SD = 1.11) and game tasks (M = 3.35,
SD = 1.52), were rated as significantly more difficult than all of the audio based tasks,
with the classical music (M = 1.40, SD = 0.74), body scan (M = 1.49, SD = 0.69) and
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audio book (M = 1.61, SD = 0.87) tasks rated very similarly as being the easiest tasks.
Body scan Selborne Audio book Classical music
Game PVSAT0.00
1.00
2.00
3.00
4.00
5.00
6.00
Mea
n ra
tings
of t
ask
diffi
culty
Figure 5.2 Mean ratings of difficulty by task
Again, figure 5.2 shows that the tasks placing demand on higher level cognitive
functions and the visuo-spatial sketchpad (PVSAT & game) were rated as
significantly more difficult than all of the audio based tasks. The Selborne extract is
given a slightly higher rating compared with the other listening tasks, and again
participant feedback suggested this was only a ‘difficult’ task in the sense that it was
hard to maintain focus on the narrative.
Measures of relaxation
For composite ratings of relaxation, the results showed that there was a significant
difference between the tasks: F(5,175) = 42.24, p < .001, ηp2 = .58, with post-hoc
analysis indicating that the PVSAT (M = 2.00, SD = 1.18) was rated as significantly
less relaxing than all of the other tasks, the Selborne audio (M = 3.90, SD = 1.22) was
rated as significantly less relaxing than all of the other audio tasks, and the guided
body scan (M = 5.87, SD = 1.07) as significantly more relaxing than all of the other
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tasks.
Body scan Selborne Audio book Classical music
Game PVSAT1.00
2.00
3.00
4.00
5.00
6.00
7.00
Mea
n ra
tings
of r
elax
atio
n
Figure 5.3. Mean rating of how relaxing participants found the tasks
Figure 5.3 shows that despite the body scan, audio book and classical music listening
tasks being rated as very similar on measures of both attention and difficulty, and
placing comparable demands on the central executive, the body scan content still
invokes a more relaxing experience. In contrast to this, and as expected, the PVSAT
was rated as much less relaxing than all of the other tasks, however despite the game
also involving high cognitive load, it was not rated as significantly less relaxing than
the audio tasks, and this is also reflected in ratings of task enjoyment (see below).
Measurement of task enjoyment
The results of the final question asking how enjoyable each task was showed that
there was a significant difference between the tasks: F(5, 120) = 9.27, p < .001, ηp2
= .28, with post-hoc analysis indicating that the Selborne extract (M = 2.84, SD =
1.41) was rated as significantly less enjoyable than all of the other tasks. Playing the
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electronic game was rated the most enjoyable (M = 5.56, SD = 1.73), but no other
comparison was significantly different (figure 5.4).
Bodyscan Selborne Audio book Classical Music
Game PVSAT2.00
3.00
4.00
5.00
6.00
7.00
Mea
n ra
tings
of e
njoy
men
t
Figure 5.4. Mean rating of how much participants enjoyed doing the tasks
In terms of using the enjoyment question as an indication of task preference, figure
5.4 shows that that with the exception of the Selborne extract, all of the tasks were
rated as comparably enjoyable. The lack of enjoyment of the Selborne extract is in
line with high ratings of boredom and reports of difficulty concentrating on the
reading narrative. Interestingly, despite the PVSAT being rated as requiring
significantly more attention, being more difficult and less relaxing than the majority
of the other tasks, this did not impact on task enjoyment.
5.3.2. Comparison of the guided body scan to the other tasks on all measures
The second aim of this study was to ascertain which tasks were rated as most closely
resembling the guided body scan for use as comparator distraction tasks in study
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three. A series of paired t-tests were conducted to compare the body scan to each of
the other tasks on the composite factors of the post-task questionnaire. Table 5.2
presents a summary of the results.
Table 5.2.
Paired t-tests to compare the guided body scan to other tasks on measures of
attention, difficulty, relaxation and enjoyment
Attention Difficulty Relaxation EnjoymentSelborne ** ** ** **Audio book ns ns ** nsClassical music ns ns * nsGame * ** ** nsPVSAT ** ** ** ns* p < .05; ** p < .01
The results indicate that while the guided body scan was rated as significantly
different to the PVSAT, game and Selborne extract on measures of attention,
difficulty and relaxation, there was no significant difference between the body scan
and listening to the audio book or classical music. In terms of ratings of task
enjoyment, the results showed that the guided body scan was not significantly
different to any of the other tasks except the Selborne extract (t = 5.42, df = 24, p
< .001). This suggests that with the exception of the Selborne extract, the body scan
was not preferred over any of the other tasks. Overall, the results suggest that the
classical music and audio book listening tasks would be the most suitable to use as
comparison distraction tasks to the guided body scan in study three.
5.4 Discussion
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The aim of the final study of this thesis is to determine whether the underlying
mechanism responsible for the observed reductions in cigarette cravings and
withdrawal symptoms following a guided body scan intervention stem from the effect
of cognitive distraction. In order to empirically test this, the guided body scan will be
compared with other cognitive distraction tasks, however there are very few existing
studies examining the effect of distraction on the negative consequences of tobacco
abstinence, a lack of validated distraction tasks, and no verified measures of
distraction as a construct. The aim of the current exploratory study was therefore to
explore how people rated different types of distraction tasks on measures of attention,
difficulty, relaxation and enjoyment, and based on the results of this, to ascertain
which tasks were most suitable comparison tasks to the guided body scan technique
for use in study three.
The guided body scan was rated as engaging a moderate amount of cognitive
attention, and compared with the other distraction tasks it was rated as engaging more
attention than the Selborne extract, less than the game and PVSAT and comparably
with both the classical music and the audio book tasks. This is in line with
expectations, as it could be argued that compared with the audio tasks, the highly
engrossing game playing and PVSAT tasks placed more demand on the central
executive via high loading of the visuo-spatial sketchpad. The game and PVSAT tasks
were however rated as significantly more difficult and stressful (see appendix 19,
figure 2 for individual stress item results) than the body scan, classical music and
audio book, so while they may be more effective as a simple distraction task, as an
intervention to reduce tobacco related cravings, there is a risk that the additional stress
element may negate the positive effects of the distraction and actually increase
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cravings. This is supported by previous research which has found that physical and
psychological stress lead to an increase in both desire to smoke and subsequent
smoking rates (e.g. al’Absi, Amunrud, & Wittmers, 2002; Buchmann, Laucht,
Schmid, Wiedemann, Mann & Zimmermann, 2010), and suggest that less difficult
and stressful tasks would lead to more effective smoking interventions.
The guided body scan was rated as significantly more relaxing than all of the other
tasks (except listening to classical music), and this is in line with previous research by
Ditto, Eclache and Goldman (2006) who investigated the short-term autonomic and
cardiovascular effects of the body scan compared with progressive muscle relaxation
or listening to an audio book extract. They found that while participants showed a
significantly greater increase in heart rate and cardiac respiratory sinus arrhythmia
(RSA) during the body scan compared with the other relaxation activities, they also
exhibited a significant decrease in cardiac pre-ejection period and diastolic blood
pressure. They argue that this indicates the body scan involves both active, arousal
promoting processes as well as a relaxation response, and supports the theory that it
may be an effective distraction intervention because while it involves active
(controlled) processing, it promotes distraction from cravings without inducing a
stress response. The body scan therefore appears to represent a favorable candidate as
an effective cognitive distraction intervention as it is rated as engaging a moderate
level of attention and is not difficult or stressful to perform. Furthermore, despite the
limited number of empirical studies looking at relaxation as a potential mechanism,
there is evidence that it does play a role in the body scan, and the direction of future
research relating to this theory is discussed more in the general discussion chapter.
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In answer to the second aim of this study, the two tasks that were rated as most
closely resembling the guided body scan were the audio book and classical music
listening conditions. This is unsurprising as they are all audio-delivered interventions
that involved similar levels of attention engagement, although the classical music
condition involved slightly more mind wandering than the body scan and audio book,
but this could be a result of the more passive nature of this task. Furthermore, unlike
the PVSAT and game playing tasks, the body scan, audio book and classical music
tasks did not involve high levels of difficulty or stress, and were not rated as boring to
listen to like the Selborne extract (see appendix 19 figure 1. for individual boredom
item results). They were also comparable on level of enjoyment, and rated as more
relaxing than the Selborne extract, game and PVSAT. As a result, the audio book
extract and classical music listening tasks will be compared to the guided body scan
on ratings of cigarette craving and withdrawal in the final study.
In terms of the limitations of this study, a relatively small sample size of 36
participants meant that exploratory factor analysis was not possible. This would have
been an extremely useful exercise in order to provide more concrete evidence relating
to the different facets of distraction as a construct. It would have also been beneficial
to compare a greater range of distraction tasks such as a non-body scan mental
imagery task or virtual reality, as these were frequently occurring tasks in the
systematic literature search. Both of these limitations were not feasible to address
within scope of study time frame and budget, although future studies looking at the
use of a wider range of cognitive distraction techniques on a larger sample of
participants would help to further our understanding of distraction as a therapeutic
strategy.
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_____________________________________________________________________
CHAPTER 6
STUDY 3: COMPARISION OF THE GUIDED BODY SCAN VERSUS
TWO DISTRACTION TASKS ON CIGARETTE CRAVINGS &
WITHDRAWAL SYMPTOMS
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6.1 Introduction
For reducing desire to smoke and tobacco withdrawal symptoms, a brief guided body
scan intervention had been shown to be effective in the short-term for temporarily
abstinent smokers (Cropley, Ussher and Charitou, 2007; Ussher et al, 2009), however
the mechanisms underlying this body scan effect have yet to be elucidated.
Furthermore, the results of study one found that the control audio (Natural History of
Selborne extract) was also effective in reducing cravings and withdrawal, casting
doubt on theories that mindfulness based interventions are unique in cultivating
unprejudiced receptivity of momentary experience, promoting self-control and
reducing reactivity to emotionally challenging situations (see chapter two). Instead it
seems more plausible that both the body scan and control audio were effective as
attention control strategies that worked by loading limited capacity working memory.
This is partially supported by the Elaborated Intrusion (EI) theory of desire
(Kavanagh et al, 2005, see chapters one, two & five), which discusses how the
generation, maintenance and manipulation of craving related mental images relies on
several high-level cognitive processes. More specifically, they argue that elements of
an image such as sensory information (e.g., the smell of cigarette smoke), generic
characteristics (e.g. the form of the cigarette packet), and specific episodes (e.g. how
good the first cigarette of the day felt), are retrieved from long-term memory, and that
central executive functions control this retrieval process. Based on this theory, if a
distraction task places sufficient demand on competing cognitive resources, it may
successfully interrupt the retrieval of desire related imagery, and ultimately disrupt the
craving process. However EI theory also argues that visual imagery (not auditory
processing) plays a central role in whether the urge for a substance is ignored or
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elaborated upon, yet the body scan and control audio do not place heavy demand on
the visuo-spatial sketchpad, and still produced reductions in craving. This suggests
that it is not necessarily sensory modality, but rather level of cognitive load that is the
crucial factor in disrupting the craving process. And in light of the results of study one
and theories of cognitive loading, it appears more likely that the body scan element of
mindfulness practice, when used as a stand-alone intervention in mindfulness naïve
participants, acts more as a cognitive distraction from cravings and withdrawal.
By this argument, other distraction interventions should also be capable of producing
a similar effect on cravings and withdrawal, and in order to further explore this
theory, study two was conducted with the intention of identifying two cognitive
distraction tasks to compare against the guided body scan on measures of desire to
smoke and withdrawal symptoms in order to test whether distraction is the underlying
mechanism. The results indicated that listening to an audio book and classical music
were rated as not being significantly different from performing a guided body scan
routine on measures of attention expenditure, task difficulty and enjoyment. The
current study therefore aims to test whether reductions in cigarette cravings and
withdrawal symptoms seen in previous research using the guided body scan are the
result of cognitive distraction by comparing it to two similarly rated distraction tasks.
It is hypothesised that the body scan and distraction tasks will all produce significant
reductions in desire to smoke and withdrawal symptoms.
6.2 Methodology
6.2.1 Participants
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Opportunity sampling was used to select the participants for the present investigation,
who were recruited using posters advertising the study (appendix 21) placed in private
companies around the Maidenhead and Slough areas, and on the University of Surrey
campus. A G-power calculation indicated that a sample size of 54 participants was
needed for a power of 95% (Cohen, 1988), with a significance level of .05 and a
effect size of .28 (medium). The sample consisted of 30 male and 24 female smokers,
aged between 18 and 60 years (M = 25.8, SD = 7.8) who smoke at least 5 cigarettes a
day (M = 10.8, SD = 5.8), and who had smoked for at least three consecutive years (M
= 8.7, SD = 7.5). Participants were paid £10 on completion of the experiment for their
involvement in the study.
6.2.2 Design
The aim of the study was to explore whether listening to a 10-minute audio book
extract or 10-minutes of classical music would produce comparable reductions in
strength of desire to smoke and tobacco withdrawal symptoms to a 10-minute guided
body scan. The independent variable was type of distraction intervention (body scan,
audio book or classical music), and the dependent variable was participants’ ratings of
desire to smoke and tobacco withdrawal symptoms made immediately before, after
and at 5, 10 and 15 minutes post-audio.
6.2.3 Interventions
The two comparison tasks were chosen based on the results of study two, which
explored a range of different distraction tasks (active and passive listening, electronic
gaming, mental arithmetic), in order to establish which ones were most closely
matched to the guided body scan in terms of how the task made the participant feel.
Compared to the other tasks, listening to the audio book and classical music was rated
152
as not being significantly different from performing the body scan in terms of the
attention requirements, task difficulty or enjoyment, and were subsequently chosen as
the two most suitable comparison tasks:
Distraction task 1: Audio book listening
The story listening task consisted of listening to a 10-minute extract (Chapters one &
two) from the audio book recording of The Hitchhiker's Guide to the Galaxy© read by
Stephen Fry (Macmillan Digital Audio, 2005). Full details of the audio extract can be
found in chapter five.
Distraction task 2: Classical music listening
The classical music listening condition consisted of participants listening to a 10-
minute segment of the Sonata in D major for Two Pianos by W. A. Mozart, K 448
(Teldec: 4509-91378-2). The segment included five minutes of first movement
(Allegro conspirito), and five minutes from the second movement (Andante). Again,
full details of the extract can be found in chapter five.
The guided body scan
After receiving brief verbal instructions about what the guided body scan entailed,
participants were guided through a 10-minute audio recording of a seated body scan
routine based on that used originally by Cropley et al (2007), and detailed fully in
chapter four.
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6.2.4 Measures
Fagerström Test for Nicotine Dependence (FTND; Heatherton et al, 1991)
The FTND is a 6-item self-report measure (appendix 5) of dependency on nicotine
that is closely related to biochemical indices of heaviness of smoking. Full details of
the reliability, internal consistency, predictive validity, and cross validation with
saliva cotinine levels can be found in chapter four. The FTND was administered to
participants in the present study to establish their background level of tobacco
dependency and explore whether this has any impact on the efficacy of the
interventions.
Mood and Physical Symptoms Scale (MPSS; West & Hajek, 2004)
The MPSS (appendix 6) is specifically designed to assess self-rated levels of the
withdrawal symptoms of irritability, tension, depression, restlessness, difficulty
concentrating and stress. Full details of coherence and reliability of the scales can be
found in chapter four. An additional question asking, “how strong is your desire to
smoke right now?” was also included as a measure of craving for a cigarette.
6.2.5 Procedure
Upon expressing interest in taking part in the study, and prior to abstinence,
participants were screened either by telephone or e-mail to check their eligibility
status by confirming that they were within the correct age range, had been smoking
long enough, and smoked an average of more than 5 cigarettes per day. Originally the
eligibility criteria for participation was to be 10 cigarettes per day, but increasing
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difficulty in recruiting participants who smoked this amount led to the lowering of the
threshold. They were also required to be able to read and write in English, not be
receiving treatment for mental health problems, not pregnant or currently trying to
conceive.
Once eligibility was established, participants were asked to either present at the
psychology laboratory, or meet at another convenient location where upon their
smoking status was verified by an expired carbon monoxide (CO) concentration of
≥15ppm. They were then given a participant information sheet to read (appendix 22),
a consent form to sign (appendix 17), and an opportunity to ask any questions. They
were then required to complete the Fagerström Test for Nicotine Dependence (FTND;
Heatherton et al, 1991), and provide further demographic information such as age,
gender, ethnic group, marital status, occupation, whether they would like to give up
smoking, how long they have been smoking, and how many serious quit attempts they
have made in the last year (appendix 9).
Participants were then requested to abstain from smoking cigarettes from 10pm that
evening, and to attend a second session at an agreed time the next day to take part in
the actual task (after approximately 12 hours of abstinence). Once overnight
abstinence was established with an exhaled CO reading of < 10ppm, and the length of
self-reported abstinence was ascertained, participants were allocated to one of the
three experimental conditions based on a random number generated via computer in
advance of their arrival. The three conditions were:
(i) Guided body scan
(ii) Audio book (The Hitchhikers Guide©)
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(iii) Classical music (Mozart)
Participants were then asked to report their baseline ratings for strength of desire to
smoke and tobacco withdrawal symptoms using the Mood and Physical Symptoms
Scale (MPSS; West & Hajek, 2004), and informed of their allocated condition. The
researcher then went through in detail what their allocated task involved and what
they would be expected to do, and asked if they have any final questions before the
audio listening began. Participants were then given an mp3 player containing the
appropriate 10-minute audio file to be listening to through in-earphones.
Immediately after the audio, participants were asked to rate their desire to smoke and
cigarette withdrawal symptoms again using the MPSS questions. They then sat
passively with minimum interaction with the researcher and asked to give further
ratings at 5, 10 and 15 minutes post-audio. This was done in order to track how
reported levels of withdrawal and cravings fluctuate as a result of each audio
intervention. Participants completed a final questionnaire asking them about the
perceived usefulness, effectiveness, familiarity and enjoyment of the intervention
(appendix 23), were then paid £10 for their time, and given an additional information
sheet (appendix 24) containing details of a number of useful quit support websites and
the free phone numbers of NHS local and national smoking helplines to take away
with them.
6.3 Results
6.3.1 Baseline comparisons
A series of one way ANOVAs were used to compare the baseline characteristics of
the three groups (body scan, audio book, classical music), and indicated that there
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were no significant differences between the groups for any of the demographic or
smoking related characteristics: Age, F(2,51) = 1.49, p = .23 (ns); Cigarettes per day,
F(2,51) = 2.58, p = .09 (ns); Years smoking, F(2,51) = 0.54, p = .58 (ns); FTND,
F(2,51) = 1.69, p = .19 (ns); Post-abstinence ECO, F(2,51) = 0.12, p = .87 (ns); Time
since last cigarette, F(2,51) = 0.62, p = .54 (ns). The means and standard deviation
for each can be seen in table 6.1.
Table 6.1
Mean ± SD of demographic and smoking characteristics by group
Body scan
(n = 18)
Audio book
(n = 18)
Classical music
(n = 18)
Age 25.5 ± 5.3 28.1 ± 10.9 23.7 ± 5.6
Cigarettes per day 12.4 ± 4.7 11.6 ± 6.9 8.4 ± 5.1
Years smoking 8.6 ± 6.3 10.1 ± 10.1 7.5 ± 5.4
FTND 4.2 ± 1.9 3.3 ± 1.9 3.1 ± 1.7
Post-abstinence ECO 3.8 ± 2.5 3.8 ± 2.2 3.5 ± 1.8
Hours since last cigarette 13.3 ± 3.1 13.7 ± 2.6 12.8 ± 1.1
FTND = Fagerström Test for Nicotine Dependence; ECO = Expired Carbon Monoxide
Chi-squared analysis indicated that there were also no significant differences between
the groups for: gender, χ2 = 1.80, df = 2, p = .41 (ns); ethnicity, χ2 = 13.8, df = 16, p
= .61 (ns); marital status, χ2 = 8.05, df = 8, p = .43 (ns); occupation, χ2 = 7.42, df = 8,
p = .49 (ns); or desire to give up, χ2 = 0.23, df = 2, p = .89 (ns). The percentage split
for each factor for each group can be seen in table 6.2.
Table 6.2
Percentages for gender, marital status, occupation, ethnicity & desire to give up smoking by group
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Body scan
(n = 18)
Audio book
(n = 18)
Classical music
(n = 18)
Men 44.4 55.6 66.7
Single 61.1 66.7 77.8
Living with partner 22.2 11.1 16.7
Professional/Manager 11.1 22.2 22.2
Student 83.3 61.1 72.2
Caucasian 77.8 77.8 66.7
Want to give up smoking 77.8 83.3 77.8
Data screening using z-scores revealed that one participant was a significant outlier on
baseline MPSS measures of depression, tension and restlessness, causing a significant
negative skewing of the data set, and so was excluded from baseline comparisons.
The resulting series of one way ANOVAs of baseline levels of strength of desire to
smoke and the six withdrawal symptoms revealed no significant differences between
the three groups: Strength of desire to smoke, F(2,50) = 1.47, p = .24 (ns); Irritability,
F(2,50) = 2.48, p = .09 (ns); Depression, F(2,50) = 3.07, p = .06 (ns); Tension, F(2,50)
= 2.64, p = .08 (ns); Restlessness, F(2,50) = 1.14, p = .33 (ns); Difficulty
concentrating, F(2,50) = 1.49, p = .24 (ns); and Stress, F(2,50) = 0.59, p = .56 (ns).
Depression had a low baseline rating across all three groups and is excluded from any
further analysis. The means and standard deviations for each item can be seen in table
6.3.
Table 6.3.
Mean ± SD of desire to smoke and MPSS withdrawal items by group
Body scan
(n = 18)
Audio book
(n = 18)
Classical music
(n = 17)
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Strength of desire to smoke 3.6 ± 0.7 3.2 ± 0.9 3.1 ± 0.9
Irritability 2.1 ± 0.9 1.7 ± 0.7 2.4 ± 1.3
Depression 1.3 ± 0.5 1.2 ± 0.5 1.2 ± 1.2
Tension 2.0 ± 1.0 1.7 ± 0.8 2.4 ± 0.9
Restlessness 2.3 ± 1.1 1.9 ± 0.8 2.5 ± 1.2
Difficulty concentrating 2.1 ± 1.0 1.8 ± 1.0 2.4 ± 1.2
Stress 1.9 ± 0.9 1.9 ± 1.2 2.2 ± 1.1
In terms of baseline correlations, those who scored higher on the FTND reported
smoking more cigarettes per day (r = .79, p < .001), gave a greater post-abstinence
ECO reading (r = .53, p < .001) and also gave higher baseline rating for strength of
desire to smoke (r = .36, p < 0.01) and irritability (r = .26, p < 0.05). As would be
expected, greater length of abstinence led to significantly lower post-abstinence
expired CO reading (r = -.53, p < .001), and higher baseline desire to smoke (r = .29,
p < .05). Years smoking was significantly positively correlated with age (r = .91, p
< .001), cigarettes smoked per day (r = .58, p < .001), FTND (r = .49, p < .001), pre-
abstinence ECO (r = .37, p < .01) and post-abstinence ECO (r = .34, p < .01).
Furthermore, all MPSS items correlated significantly with each other.
6.3.2 Data screening
Data screening was conducted in order to highlight any participants who reported a
very low desire to smoke at baseline. In other words, those who reported their desire
to smoke before listening to the audio intervention as 1 (not at all) were excluded
from the dataset, and this led to the exclusion of one participant from the audio book
group. Furthermore, reliability analysis of the five remaining MPSS items showed
high inter-item correlations and a high level of internal consistency (α = .90), so for
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all further analyses they were grouped together and treated as a single item labelled
‘withdrawal symptoms’.
6.3.3 Changes in strength of desire to smoke
As per the method used by Cropley, Ussher and Charitou (2007), for both desire to
smoke and composite withdrawal symptom items, baseline ratings were subtracted
from ratings taken immediately after the intervention and at 5, 10 and 15 minutes
post-intervention, and the change scores analysed using group (body scan/ audio
book/ classical music) by time (immediately, 5, 10 and 15 minutes post-intervention)
repeated-measures analysis of variance (ANOVA). The results for desire to smoke (all
using Greenhouse-Geisser estimates of sphericity) indicated that while there was no
significant interaction effect: F(4.48, 111.96) = 1.85, p = .12 (ns), there was a
significant main effect of group: F(2, 50) = 4.58, p < .05, ηp2 = .16. More specifically,
post-hoc analysis using Bonferroni correction showed that there was a significant
difference between the change in body scan and audio book ratings, with the body
scan group showing a greater reduction in desire to smoke relative to the audio book
group (M = -1.15 versus M = -0.16 respectively). There was no significant difference
between the classical music and either the body scan or audio book, although the
difference in change between the body scan and classical music ratings approached
significance (p = .07). Figure 6.1 shows how similarly the classical music and audio
book groups rated their desire to smoke compared with the larger reduction by the
body scan group.
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0 mins 5 mins 10 mins 15 mins
-2.00
-1.50
-1.00
-0.50
0.00
0.50 Body scan
Audio book
Classical musicM
ean
chan
ge in
des
ire to
smok
e
Figure 6.1 Mean change in ratings of desire to smoke by group
There was also a significant main effect of time on desire to smoke: F(2.24, 111.96) =
10.13, p < .001, ηp2 = .17, with a series of paired t-tests showing that there were
significant differences between pre- and post- intervention ratings up to 10 minutes
post-task. The mean, standard deviation and significance level for each time point are
shown in table 6.4.
Table 6.4
Mean ± SD and t-test results for desire to smoke ratings by time point
Immediately
pre-audio
Immediately
post-audio5 minutes after 10 minutes after 15 minutes after
3.28 ± 0.84 2.55 ± 1.12 ** 2.64 ± 1.06 ** 2.89 ± 1.09 ** 3.04 ± 1.11 (ns)
** p < .01; * p < .05
To summarise the results for desire to smoke, the body scan was significantly more
effective than the audio book intervention at reducing cravings, although there was no
difference between the body scan and the classical music. Furthermore, irrespective of
group, the audio intervention had a significant effect on ratings of desire to smoke up
to 10-minutes post task.
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6.3.4 Changes in strength of withdrawal symptoms
The results for ratings of withdrawal symptoms (using Greenhouse-Geisser estimates
of sphericity) showed that there was no significant interaction effect: F(3.15, 78.80) =
0.28, p = .85 (ns), and no significant main effect of group: F(2, 50) = 2.88, p = .07
(ns), but there was a significant main effect of time: F(1.58, 78.80) = 5.14, p < .01, ηp2
= 0.9. This indicates that irrespective of group, the interventions still had an effect on
withdrawal symptom ratings over the course of the time points measured, however it
is worth noting that rating changes were less than one point different (on a seven point
scale) to baseline levels at all times (see figure 6.2).
0 mins 5 mins 10 mins 15 mins
-1.00
-0.80
-0.60
-0.40
-0.20
0.00
0.20
0.40 Body scan
Audio book
Classical music
Mea
n ch
ange
in w
ithdr
awal
sym
ptom
s
Figure 6.2 Mean change in ratings of withdrawal symptoms by group
To further explore the significant main effect of time, a series of paired t-tests were
conducted which showed there were significant differences between pre- and post-
intervention ratings up to 10 minutes post-task. The mean, standard deviation and
significance level for each time point are shown in table 6.5.
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Table 6.5
Mean ± SD and t-test results for composite withdrawal symptom ratings by time point
Immediately
pre-audio
Immediately
post-audio5 minutes after 10 minutes after 15 minutes after
2.08 ± 1.05 1.65 ± 0.86 ** 1.70 ± 0.84 ** 1.76 ± 0.85 ** 1.91 ± 0.97 (ns)
** p < .01; * p < .05
To summarise the results for ratings of withdrawal symptoms, there was no
significant difference between the ratings given by participants in the body scan,
audio book or classical music listening conditions, however irrespective of group, the
audio intervention was effective in reducing ratings up to 10 minutes post-
intervention.
6.3.4 Credibility of interventions
In order to explore how the participants in this study perceived the different audio
interventions, measures of usefulness and effectiveness were included. Analysis
indicated that in terms of usefulness, the body scan was rated as most useful (mean =
3.28, SD = 1.02), followed by the classical music (M = 3.06, SD = 1.26), with the
audio book rated the least useful (M = 2.44, SD = 1.29). The same applied to ratings
of effectiveness, with body scan rated as most effective (M = 3.00, SD = 0.91)
followed by classical music (M = 2.50, SD = 0.99), and the audio book rated the least
effective (M = 2.41, SD = 0.94). This translates as the body scan and classical music
conditions both being rated as “moderately useful” compared with the audio book
being rated as “slightly useful”, and the body scan as “moderately effective”
compared with the other two audios rated as only “slightly effective”. Further
ANOVAs were performed in order to compare the three groups for any significant
differences in the two measures of credibility, with the results indicating that there
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was no significant difference in how useful participants found the interventions for
relieving their desire to smoke; F (2,50) = 0.76, p = .47 (ns), or how effective they
thought the interventions would be for most smokers; F (2,50) = 2.00, p = .15, (ns).
Additional measures of familiarity and enjoyment were also included in order to
explore whether there were any correlations between these two factors and ratings of
credibility. In terms of familiarity, the “Hitchhikers Guide to the Galaxy” audio book
extract was rated as the most familiar (M = 2.23, SD = 1.48, “moderately familiar”),
followed by the Mozart classical music extract (M = 1.67, SD = 1.23, “not at all
familiar”), with the guided body scan rated the least familiar (M = 1.54, SD = 0.97,
“not at all familiar”). The classical music was rated as the most enjoyable (M = 3.67,
SD = 1.30), followed by the body scan (M = 3.54, SD = 1.33), and then the audio
book (M = 3.23, SD = 0.93). All three audio interventions were rated very closely in
terms of enjoyment, with mean scores translating as “moderately enjoyable”.
ANOVAs were performed in order to compare the three groups for any significant
differences in familiarity and enjoyment, with the results indicating that there was no
significant difference in ratings of familiarity: F(2,35) = 1.13, p = .33 (ns), or
enjoyment: F(2,35) = 0.44, p = .65 (ns).
Finally, simple regression analysis on data from all 54 participants was performed to
examine whether level of task enjoyment was able to predict how useful and effective
they were rated. The results showed significant regression equations for enjoyment
predicting usefulness: F(1,36) = 9.39, p < .01, with an R2 of .21, and enjoyment
predicting effectiveness: F(1,36) = 24.90, p < .001, with an R2 of .41. This suggests
that ratings of enjoyment were responsible for 21% of the variance in ratings of
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usefulness, and 41% of the variance in effectiveness ratings. It is interesting to note
however, that being familiar with the audio content was not significant predictor of
enjoyment: F(1,36) = 2.67, p = .11 (ns), and enjoyment was not significantly
correlated with changes in strength of desire to smoke between the pre- and post-
audio ratings: r = -.19, n = 38, p = .26 (ns).
To summarise, the results of this study showed that listening to a brief guided body
scan produced significantly lower ratings of desire to smoke compared to the audio
book distraction task, although there was no significant difference between any of the
tasks in terms of withdrawal symptom ratings. There was however a significant effect
of time for all of the tasks, with reductions in ratings of strength of desire to smoke
and tobacco withdrawal symptoms up to 10 minutes post-audio relative to baseline,
irrespective of the audio content listened to. Enjoyment of the audio content was an
important factor in predicting both the usefulness and effectiveness of the
interventions, however it ultimately failed to correlate with any actual reductions in
ratings of strength of desire to smoke.
6.4 Discussion
This study examined the effects of a brief guided body scan versus distraction (audio
book or classical music listening) on temporarily abstinent smokers. Relative to
baseline, ratings for strength of desire to smoke were reduced up to 10 minutes post
intervention, however the results indicated that body scan was significantly more
effective than the audio book intervention. As all three tasks did not produce the same
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effect, it suggests that the reductions observed following the body scan routine are not
simply the result of cognitive distraction, but unmeasured factors such as its impact on
negative affect or the promotion of a relaxation response. For ratings of withdrawal
symptoms however, there was no significant difference between any of the
interventions groups, and ratings were again significantly reduced up to 10 minutes
post-task. This suggests that distraction might play a more central role in moderating
the impact of withdrawal symptoms, as the body scan did not produce significantly
different ratings to either of the two distraction tasks, and reductions were observed
irrespective of intervention group. This leads to the partial rejection of the hypothesis
that all three tasks would reduce ratings of desire to smoke and withdrawal symptoms,
as this only held true for ratings of withdrawal.
In terms of exploring the theory that the body scan reduces cravings via the
moderation of negative affect, Kavanagh, Andrade & May (2005) contend that
negative affect can be both responsible for triggering intrusions, and occurs as a
consequence of desire by priming awareness of the signs of physiological withdrawal
and the activities that may lead to relief from this negative state. Once craving-related
thoughts emerge into consciousness, attention to the feelings associated with
deprivation is further primed, and the disparity between current and desired states
result in a source of negative affect. As negative emotions prime awareness to
abstinence related withdrawal symptoms, so it is possible that the body scan reduces
cravings via a reduction in negative affect. This idea is supported by the findings of
Arch and Craske (2006) who compared emotion regulation responses to laboratory
induced stressors before and after a 15-minute focused breathing exercise (similar to
the body scan), mind wandering or worrying. In response to a series of positive,
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negative and neutral picture slides the focused breathing group maintained a
consistent, positive response to the neutral slides both before and after induction,
whereas the control groups both responded significantly more negatively after the
induction compared to before. The focused breathing group also reported lower
negative affect and overall emotional volatility in response to the post-intervention
slides. Whilst the study did not use a body scan per se, the research does suggest that
mindfulness based focused breathing exercises hold the ability to moderate negative
affect, reduce emotional volatility, and therefore reduce reactivity to the emotionally
challenging situation presented by tobacco abstinence. Unfortunately, whilst there are
a number of studies examining the effect of a variety of mindfulness based
intervention on levels of negative affect (e.g. Gifford et al, 2004; Bowen & Marlatt,
2009; Rogojanski, Vettese & Antony, 2011; Ruscio et al, 2016), there are currently no
published studies directly examining the effects of the body scan, and future research
in this area is required.
The idea that the body scan may reduce cravings and withdrawal due to the induction
of a relaxation response has been tentatively proposed by Ussher et al (2006), and was
even described by Cropley et al (2007) as a ‘guided relaxation routine’. Furthermore,
study two of this thesis found that the body scan was rated as significantly more
relaxing than all of the other distraction tasks. It is therefore possible that a relaxation
response is at least partly responsible for the significant reduction in cravings reported
by the body scan group compared with the audio book group. To date however, only
one small study by Ditto, Eclache and Goldman (2006; described in chapter five,
section 5.4) has examined the body scan in comparison to other relaxation techniques
(such as progressive muscle relaxation), and the research focused solely on short-term
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autonomic and cardiovascular effects. They found that overall the body scan produced
physiological patterns that were both consistent with and distinct from other forms of
relaxation techniques, and this highlights the need for a broader spectrum of research
in order to fully understand the factors underlying a potential relaxation response.
The results of the current study again sit in contrast to the EI theory of desire
(Kavanagh, Andrade & May, 2005), which places more emphasis on the role of visual
imagery, rather than auditory load in blocking craving related thoughts, as cognitive
processing of all three audio delivered tasks would be expected to place more demand
on the phonological loop than the visuo-spatial sketchpad. This supports the idea that
smoking related thoughts can be successfully disrupted by auditory distraction tasks
as well as visual imagery tasks, and that the craving process may not be exclusively
supported by visual imagery as proposed by EI theory. This is also in line with a study
by Teasdale, Proctor, Lloyd and Baddeley (1993), who explored the effect of both
verbal and visual load on intrusive thoughts, and found that it was the amount of
information being processed, rather than the format, that determined intrusion rates.
They concluded that thoughts only reach awareness if they are able to access central
executive resources, leaving no opportunity for task irrelevant thoughts to be
elaborated upon. In terms of the results of the current study, this suggests that
irrespective of the demands placed on competing sensory modalities, the cognitive
load associated with the body scan was greater than that of the audio book distraction
task, and therefore more successful in blocking intrusive thoughts relating to the
desire for a cigarette. In the absence of data regarding the way individuals processed
the audio information (i.e. by creating visual images or not), it does however make it
difficult to draw any firm conclusions regarding levels of demand on different sensory
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modalities.
For withdrawal symptoms, there was no difference in efficacy between the body scan
and either distraction task, but a reduction in ratings up to 10 minutes post task
relative to baseline irrespective of task type. This suggests that the cognitive load
involved in all of the interventions was sufficient to effectively distract attention away
from the psychological and physiological consequences of nicotine withdrawal, at
least in the short term. It must be noted however, that baseline levels of withdrawal
were relatively low, with mean ratings translating as feeling only “slightly”
withdrawn, so it may not have taken a particularly high loading distraction task to
prevent them from being attended to and elaborated upon. Furthermore, levels of
nicotine dependence as measured by the FTND were also relatively low, with almost
70% of the sample reporting ‘low’ or ‘very low’ levels. This is mainly due to the high
proportion of students in the sample (72%), who are typically ‘light’ opportunistic
smokers (Okuyemi, Harris, Scheibmeir, Choi, Powell & Ahluwalia, 2002).
Consequently, there was not enough data to reliably explore the effects of the
interventions on heavier smokers with a higher level of nicotine dependence. This is
particularly problematic as heavy smokers have been found to exhibit greater
attentional bias to salient smoking related cues than lighter smokers (e.g. Zack,
Belsito, Scher, Eissenberg & Corrigall, 2001; Mogg & Bradley, 2002), and may
therefore be less susceptible to the effects of distraction during abstinence. This issue
requires further exploration via replication with a more ecologically valid sample of
smokers.
The current study does however indicate that as well as the guided body scan,
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distraction strategies also have the potential to moderate desire for a cigarette and
tobacco withdrawal symptoms during temporary smoking abstinence. Urges are
episodic in nature, rather than constant experiences, with craving episodes typically
lasting around 16 minutes (Shiffman, Engberg, Paty, Perz, Gnys, Kassel & Hickcox,
1997). The benefits of the distraction tasks were apparent 10 minutes post-task for
cravings and withdrawal symptoms, and this indicates that distraction may be a useful
coping mechanism during periods of forced abstinence (e.g. long haul flight).
Furthermore, it is particularly attractive due to the low cost and ease with which it
could be incorporated into a smoking cessation programme, however whilst there was
very little difference in the enjoyment ratings between the three tasks, there was a
significant link between ratings of enjoyment and both usefulness and effectiveness.
This indicates that matching an enjoyable distraction task to the individual could have
important implication in terms of how likely they are to use the intervention in the
longer term. One issue that may impact the efficacy of all the tasks longer term is
whether the initial high loading of the central executive is due to the novelty factor,
and whether this would wane over time. A study by Ruscio et al (2016) did however
show a positive effect of utilising an urge surfing technique and four other guided
mindfulness routines in the management of cravings over the course of two weeks,
although a longer period of data collection would be necessary to make any firm
conclusions regarding the repeated use of the guided body scan or distraction tasks.
To conclude, both the guided body scan and distraction tasks were effective over time
in reducing desire to smoke and withdrawal symptoms, and it seems feasible that this
effect is the result of loading of the limited capacity central executive, rather than the
visuo-spatial sketchpad per se. Additionally, the body scan was found to be more
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effective than the audio book in moderating cravings, and leads to the conclusion that
whilst cognitive distraction cannot be ruled out as one of the mechanisms by which
the body scan is able to reduce the negative consequences of tobacco withdrawal, its
impact on negative affect and the promotion of a relaxation response also needs
further investigation.
CHAPTER 7
SUMMARY OF FINDINGS, CONCLUSIONS AND FUTURE DIRECTIONS
7.1 Introduction
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Helping smokers to achieve long-term cessation is crucial in tackling one of the most
significant public health challenges facing the world today. However despite the
positive impact of government initiatives such as smoking bans and cessation
schemes, smoking prevalence has plateaued at around 20% (OPN; Office for National
Statistics; ONS, 2013a). Furthermore, whilst there are many different types of
pharmaceutical products available, many smokers do not want to use nicotine
dependence medications, as they hold low expectations of their ability to effectively
control cravings (Vogt, Hall & Marteau, 2008). This highlights the importance of
developing and testing alternative non-pharmaceutical strategies, such as
mindfulness-based interventions.
Whilst it’s origin stems from ancient Buddhist meditation, modern mindfulness
practice teaches participants to recognise that their internal experiences are both
temporary and subjective, and focuses on the acceptance of thoughts, feelings and
sensations as they occur without making judgements or imposing meaning (Kabat-
Zinn, 2003). Mindfulness interventions have been used clinically the treat a variety of
physical and psychological issues since the late 1970s, although it wasn’t applied to
the field of smoking cessation until 2002 with the publication of two small studies
(Altner, 2002; Michalsen et al, 2002) that each used a traditional 8-week Mindfulness
Based Stress Reduction (MBSR) programme combined with NRT to help smokers
quit. Later studies have modified the original MBSR programme to create new
cessation interventions such as Acceptance and Commitment Therapy (e.g. Gifford et
al, 2004), and Mindfulness Based Relapse Preventions (Bowen et al, 2009), or drawn
on individual features to develop interventions that treat the acute effects of tobacco
abstinence such as ‘urge surfing’ (e.g. Rogojanski, Vettese & Antony, 2011) and the
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guided body scan (e.g. Ussher et al, 2009). The utility of both acute mindfulness
based interventions and smoking cessation programmes are supported by the results
of the systematic review conducted in chapter three of this thesis, with a meta-analysis
of eight cessation studies indicating that participants were 70% more likely to be
abstinent at final follow-up if randomised to the mindfulness arm of the trials. This
suggests that mindfulness based interventions have the potential to produce efficacy
levels which are comparable to that of other behavioural interventions (see Lancaster
& Stead, 2005 for a comprehensive systematic review), and justifies the need to
further explore how they can be most effectively used in the management of tobacco
cravings.
Earlier research has shown that a brief audio guided body scan routine is effective in
reducing both cravings for a cigarette and a range of nicotine withdrawal symptoms
up to 30 minutes post intervention in temporarily abstinent smokers (Cropley et al,
2007, Ussher et al, 2009). The results of these studies, whilst significant, were
however relatively modest, with both suggesting that a more powerful effect may be
possible by combining the body scan with traditional nicotine replacement therapy.
Furthermore, neither put forward any concrete theories as to the underlying
mechanisms responsible for the positive effects observed. The current thesis set out to
address both of these questions, with the investigation presented over the course of
three quantitative empirical studies. This chapter will now summarise the main
findings of these studies and discuss their implications in relation to both the
Elaborated Intrusion (EI) model of desire (Kavanagh et al, 2005) and theories of
mindfulness mechanisms, as well as considering methodological limitations and
providing suggestions for addressing them in future research.
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7.2 Summary of empirical studies
7.2.1 Study 1
A high dose treatment regimen of NRT patches have been shown to almost
completely eliminate cravings and withdrawal symptoms (Dale et al, 1995), and
improve abstinence rates over a placebo (Shiffman et al, 1995), however their use as a
cessation aid still leads to substantial relapse rates of between 30 – 59% (Stead et al,
2012). The reasons for this relatively high relapse rate have focused on the possibility
that whilst patches eliminate underlying background symptoms, they do not protect
the smoker from acute reactivity to situational cues (Shiffman, Paty, Gnys, Kassel &
Hickcox, 1996). With this in mind, there are two main theories regarding the
mechanism responsible for the positive effects of mindfulness interventions for
smokers; enhanced attentional control through the cultivation of flexible awareness,
and improved emotion regulation leading to better tolerance of unpleasant emotional
stimuli during a craving episode without resorting to cognitive reactivity (see chapter
two for a full discussion). This provided the rationale for study one, which was the
first placebo controlled RCT to explore whether combining a brief mindfulness
intervention (the guided body scan) with NRT could produce a synergistic effect in
reducing the desire for a cigarette and tobacco withdrawal symptoms.
The methodology of study one involved temporarily abstinent smokers being
randomly assigned to one of four experimental conditions; NRT patch plus a 10-
minute audio delivered guided body scan, NRT patch plus a 10-minute control audio,
placebo patch plus the body scan, and placebo patch plus control audio. Ratings of
desire to smoke and withdrawal symptoms were recorded before, after, and at 5, 10,
20 and 30 minutes after listening to the audio intervention. The results indicated that
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contrary to expectations, there was no significant difference between any of the
groups across the course of the time points measured. Irrespective of patch or audio
condition however, the interventions still produced a significant effect on ratings over
time, with desire to smoke significantly reduced up to 10 minutes post audio, and
withdrawal symptoms up to 30 minutes post audio. Furthermore, neither the placebo
nor the NRT patches had any significant impact on ratings, suggesting the presence of
a substantial anti-placebo effect in the experimental arm of the study. Whilst this was
not the intended or expected effect, previous studies have also found this result. For
example, Teneggi et al (2002) report that compared with free smoking, there was no
significant difference in withdrawal symptom levels between those on NRT patches
and placebo patches, and a review by Dar & Frenk (2004) explored the self-
administration of pure nicotine and found that neither smokers nor non-smokers
showed a preference for nicotine over placebo in any of the studies reviewed. In light
of this, the results of study one cast further doubt onto the widely held belief that
nicotine is the primary agent motivating tobacco smoking, as fully replacing nicotine
should effectively counteract the effects of nicotine withdrawal and eliminate the
desire for a cigarette. Instead the results highlight the importance of treating the non-
pharmacological factors that contribute to the maintenance of tobacco addiction, and
support the need for effective behavioural interventions.
The results also indicated that both the body scan and control audio conditions had a
positive impact in reducing desire to smoke and withdrawal symptom ratings, and
despite leading to the rejection of the original synergy hypothesis, this sent the
research in a new and unexpected direction in terms of extrapolating the underlying
mechanisms. In light of the control audio also producing reductions, the theory that a
brief mindfulness-based body scan intervention reduces cravings and withdrawal
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symptoms via the promotion of non-judgemental acceptance of the negative
consequences of tobacco abstinence seemed unlikely. The idea that attention control
may be at least partly responsible did however seem more plausible, as both audio
interventions may be acting as a form of cognitive distraction that effectively diverts
participants’ attention away from craving focused ruminations. If effective cognitive
distraction is a primary contributing factor in the reductions observed, it potentially
opens up a huge new area of intervention development. The next two studies of this
thesis consequently aimed to explore the theory that the guided body scan is a form of
cognitive distraction, and to establish whether other similar forms of distraction were
capable of producing the same effects.
7.2.2 Study 2
Findings from study one suggested that cognitive distraction was a possible
contributing factor underlying the salutary effects of the body scan on cravings and
withdrawal symptoms in abstinent smokers; so naturally, the next step was to test this
hypothesis. Research on attention, working memory and distraction suggested that the
body scan might distract smokers from craving related thoughts by engaging high-
level cognitive processes that compete for limited attentional resources. The central
executive is thought to be responsible for co-ordinating incoming information from
the visuo-spatial sketchpad and phonological loop, however due to limited capacity,
selective attention is applied in order to focus cognitive resources more efficiently
towards task relevant goals (Gazzaley & Nobre, 2012). The process of applying
selective attention is however susceptible to disruption and bias, with cognitive
research suggesting that for a distraction task to be effective, it should involve a
perceptual load that is greater than that of the original task (Lavie, 1995), require
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controlled (active) rather than automatic (passive) processing (McCaul & Malott,
1984), and employ competing sensory modalities (Wickens, 2002).
One theory that has directly explored the impact of distraction on tobacco cravings is
the Elaborated Intrusion (EI) theory of desire (Kavanagh et al, 2005; See chapters one
and five for a full discussion). EI theory argues that the generation and maintenance
of craving related mental images (which sustain a craving episode) relies on several
high-level cognitive processes, and that if a distraction task places sufficient demand
on competing cognitive resources, it can successfully interrupt the retrieval of
smoking related thoughts and disrupt the craving process. If this is the case for the
body scan, then it should be possible to compare it to other distraction tasks that
utilise similar competing resources in order to test whether they produce the same
effect. However upon researching potential distraction tasks to use as a comparator to
the body scan, it became clear that there were very few existing studies examining the
positive effect of distraction on the negative consequences of tobacco abstinence, a
lack of validated distraction tasks, and no verified measures of distraction as a
construct. In order to impose a framework for selecting the most appropriate tasks to
compare to the body scan, a wide-ranging systematic literature review of studies
utilising any kind of distraction task was conducted. The resulting 341 tasks were
categorised according to demand on sensory modality and frequency of occurrence in
the literature, with the five most commonly occurring tasks engaging differing levels
of attention and sensory modalities being chosen for further exploration. These tasks
were: (1) Passive text listening (Selborne extract); (2) Active audio book listening
(Hitchhikers Guide); (3) Classical music listening (Mozart); (4) Electronic game
playing (Bejewelled); (5) Computer based mental arithmetic (PVSAT).
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The methodology of study two involved participants rating the body scan and five
chosen distraction tasks on measures of attention, difficulty, relaxation and enjoyment
with a view to choosing the two rated as most similar to the body scan for use in study
three. The results indicated that while the game and PVSAT were rated as engaging
the most attention and therefore placing the most demand on competing central
executive functioning (via the visuo-spatial sketchpad), they were also rated as
significantly more difficult and stressful than the other tasks. As stress can lead to an
increase in desire to smoke (al’Absi et al, 2002), these tasks were discounted from
being used as comparator tasks. The Selborne listening task, whilst placing similar
demand on the phonological loop to the body scan, was rated as engaging
significantly less attention while at the same time being rated as significantly more
difficult and less enjoyable than the body scan. Consequently it was also eliminated
due to being a potential stressor, and failing to involve sufficient perceptual loading.
By contrast, the audio book and classical music listening tasks were rated as being not
significantly different to the body scan in terms of attention expenditure, task
difficulty and enjoyment, even though the body scan was still rated as significantly
more relaxing than all of the tasks. This suggests that along with placing similar levels
of demand on the phonological loop, these two tasks were not likely to provoke a
stress response, and therefore represented the best cognitive distractor candidates for
comparing to the guided body scan in study three.
7.2.3 Study 3
Based on the theory that the guided body scan, audio book and classical music
listening tasks can all be thought of as a form of cognitive distraction, study three was
designed to test the hypothesis that they would all result in a decrease in the desire to
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smoke and withdrawal symptoms in temporarily abstinent smokers. The methodology
involved smokers who had been abstinent for at least 12 hours being randomly
assigned to one of three experimental conditions; 10 minutes of listening to either a
guided body scan routine, an audio book extract (Hitchhikers Guide) or classical
music (Mozart). Ratings for the desire to smoke and withdrawal symptoms were
recorded before, after, and at 5, 10 and 15 minutes post-audio task, with the results
indicating that relative to baseline, ratings for strength of desire to smoke and
withdrawal symptoms were reduced up to 10 minutes post intervention.
In line with the hypothesis, despite a significant reduction between pre and post
intervention ratings of withdrawal, there was no significant difference between the
ratings given by the three groups. This indicates that they all produced comparable
effects on withdrawal, and that distraction may be responsible for moderating the
withdrawal symptoms associated with tobacco abstinence during the body scan. For
ratings of desire to smoke however, the hypothesis had to be rejected because the
body scan was found to be significantly more effective than the audio book at
reducing cravings, and the difference between the body scan and classical music
listening group also approached significance. As the body scan produced a greater
effect on desire to smoke than the two distraction tasks, it suggests that the superior
reductions observed were not simply the result of cognitive distraction, but may be
attributed to unmeasured factors such as its impact on negative affect or the
promotion of a relaxation response. Alternative theories regarding the underlying
mechanisms are discussed more in section 7.3 of this chapter.
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The difference in findings for withdrawal symptoms and desire to smoke also suggest
that whilst feelings of withdrawal may be vulnerable to disruption via cognitive
distraction, the desire for a cigarette is less susceptible. Even if distraction is a partial
mechanism of the body scan, the results indicate that the audio book and classical
music tasks only placed enough demand on the central executive to negate the
experience of withdrawal symptoms, whereas the body scan involved sufficient
cognitive loading to also successfully disrupt cravings. It must be noted however that
participants only reported feeling ‘slightly’ withdrawn at baseline compared with
higher baseline ratings for the desire for a cigarette, so it may not have taken a
particularly high loading distraction task to prevent withdrawal related thoughts from
being attended to. Whilst it is clear that the body scan is an effective intervention for
reducing both withdrawal symptoms and the desire to smoke, replication with a
sample of participants with higher baseline levels of withdrawal is needed to fully
clarify whether cognitive distraction tasks are truly capable of moderating withdrawal
symptoms.
7.2.4 Summary of findings
Overall, the three empirical studies presented in this thesis provide further evidence
for the efficacy of the guided body scan as a strategy for moderating cigarette
cravings and tobacco withdrawal symptoms. In light of evidence that a combination
of pharmacotherapy and behavioural support can result in even greater success rates
than either strategy alone (Stead & Lancaster, 2012), study one was the first placebo-
controlled RCT to examine how the body scan interacts with traditional nicotine
replacement therapy. Unfortunately, the magnitude of an anti-placebo effect in the
experimental arm of the trial meant that neither the nicotine nor placebo patches had
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an effect on ratings of withdrawal symptoms and tobacco cravings. The results did
however show that the body scan produced significant post intervention reductions
relative to baseline, whilst unexpectedly finding that the control audio also yielded
similar levels of efficacy. This cast doubt on the theory that the body scan reduces
cravings and withdrawal symptoms via the promotion of non-judgemental acceptance,
although the idea that both audio interventions acted as a form of cognitive distraction
seemed more plausible.
The secondary aim of the research was therefore to explore whether cognitive
distraction is a possible mechanism underlying the efficacy of the body scan, with
study three comparing the guided body scan routine to two distraction tasks utilising
the same sensory modality, similar levels of attention expenditure and ratings of
difficulty. The results indicated that relative to baseline, all three interventions
produced reductions in withdrawal symptoms up to 10 minutes post task, however the
body scan out performed the two distraction tasks in reducing the desire to smoke.
This implies that whilst withdrawal might be vulnerable to disruption via cognitive
distraction, the desire for a cigarette is less susceptible, and also suggests that the
body scan provides additional benefits that may stem from the moderation of negative
affect or a relaxation response. The following section will now discuss these ideas in
more depth.
7.3.Underlying mechanisms of the body scan
7.3.1 Cognitive distraction
Whilst the findings from this thesis supports the EI theory of desire argument that
competition for limited cognitive resources can lead to the successful interruption of
the craving process, EI theory places particular importance on the role of visual
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imagery. More specifically, Kavanagh and colleagues contend that the retrieval and
manipulation of craving related mental images allows the elaboration of craving
related thoughts, and studies have found that the loading of the visuo-spatial
sketchpad element of working memory is the key to disrupting this process and
reducing cravings (e.g. May, Andrade, Panabokke & Kavanagh, 2010; Andrade,
Pears, May & Kavanagh, 2012). In contrast to this, the results from studies one and
three suggest that auditory loading distraction tasks can also be effective in reducing
cravings via disruption of the elaboration process, without placing competing demand
on the visuo-spatial sketchpad. The findings also uphold Lavie’s (1995) load theory of
attention, that it is the level of perceptual load rather than the demand placed on
specific sensory modalities that influences the likelihood of non-craving related
information being able to disrupt the craving process. The need for sufficient
cognitive loading is further supported by May et al (2012) who found that compared
to the body scan, simple mind wandering instructions did not reduce the frequency of
smoking related thoughts, although study three of this thesis indicated that nicotine
withdrawal symptoms are more susceptible to disruption than the desire for a
cigarette. Nonetheless, this leads to the conclusion that both visual and auditory
distraction tasks can be used to successfully disrupt the craving process, although the
level of cognitive loading must be sufficient to prevent elaboration from occurring.
In line with this, McCaul and Malott (1984) contend that a successful distraction task
must involve controlled (active) rather than automatic (passive) processing. They
argue that the craving process must be assumed to be a controlled process, because if
it were automatic, processing and response mechanisms would occur without drawing
on attentional resources, and distraction would be ineffective. They also state that the
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distraction task itself must also involve controlled rather than automatic processing, as
it must utilise sufficient attentional resources in order to limit the capacity for the
controlled processing of smoking related thoughts. This may explain why the body
scan was more effective than either the classical music or audio book in reducing the
desire to smoke, as the body scan audio involved instructions to focus the breath on
different areas of the body, and could therefore be thought of as involving controlled
processing. On the other hand, the other two audio interventions did not specifically
require participants to engage with the narrative and may therefore involve only
passive processing, which failed to utilise sufficient attentional resources. To further
investigate this idea, future research would benefit from exploring a wider range of
tasks, and ascertaining more precise levels of participant engagement.
To conclude, the results from this thesis suggest three things in relation to the idea
that cognitive distraction is a mechanism underlying the effect of the body scan on
tobacco cravings and withdrawal; firstly, that audio distraction tasks (as well as visual
tasks) can be used to successfully disrupt the craving process, suggesting that the
craving process is not exclusively supported by visual imagery as proposed by EI
theory. Secondly, that the level of cognitive loading must be sufficient to prevent the
process of elaboration of smoking related thoughts from occurring, and thirdly that a
successful task must involve controlled rather than automatic processing in order to
achieve a sufficiently high demand on attentional resources.
7.3.2 Relaxation response
Whilst cognitive distraction does appear to be at least partly responsible for the
observed reductions in the desire to smoke and withdrawal symptoms, that the body
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scan produced significantly greater reductions in desire to smoke compared with the
audio book, and near significant differences to the classical music condition in study
three suggests that additional mechanisms are operating. Studies looking specifically
at the body scan as a smoking intervention have yet to proffer any concrete theories as
to the underlying mechanisms, although the promotion of a relaxation response has
been tentatively suggested (e.g. Ussher et al, 2009). So far, only one study has
compared the body scan to other relaxation techniques (Ditto, Eclache & Goldman,
2006), and this focused purely on the short-term autonomic and cardiovascular effects
rather than it’s impact on tobacco cravings. They did however find that the body scan
involved arousal promoting processes as well as a relaxation response, and combined
with the results of study three, this suggests that it may help smokers by providing
distraction from craving related thoughts whilst negating the effects of withdrawal
induced stress. A lack of studies means that it is not currently possible to draw any
firmer conclusions, and further research involving samples of smokers would be
beneficial.
7.3.3 Moderation of negative affect
In studies of abstinent smokers, the magnitude of stress responses
and negative affect have both been found to predict relapse (Sinha,
Shaham & Heilig, 2011), so it is only natural that the moderation of
abstinence related negative affect has been proposed as a potential
mechanism underlying the results of mindfulness based smoking
interventions. Currently there are no studies specifically exploring
the effect of the body scan on stress or negative affect, however a
study by Arch and Crask (2006) found that a brief 15-minute focused
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breathing exercise (similar to the body scan) was capable of producing lower negative
affect and overall emotional volatility in response to a stress induction procedure
compared with mind wandering or worrying. This suggests that the body scan could
reduce cravings and withdrawal via a similar mechanism, as the guided routine may
reduce reactivity to the emotionally challenging situation presented by tobacco
abstinence.
Whilst not focusing on the guided body scan exclusively, a more recent neurological
study by Kober, Brewer, Height and Sinha (in press) examined neural stress reactivity
in smokers enrolled on either a ‘Mindfulness Training for Smokers’ or a ‘Freedom
from Smoking’ programme. Their findings indicated that greater abstinence at
follow-up was associated with lower neural reactivity to stressful
scenarios in the amygdala, mid-insula and hippocampal regions of
the brain, and that reactivity was significantly lower in the
mindfulness training participants who consequently reported greater
reductions in smoking. Taken together with the findings from Arch
and Craske (2006), this suggests that a reduction in emotional
reactivity is a serious contender as a mechanism underlying the
efficacy of the body scan.
7.4 The body scan as a smoking intervention
Previous research examining the acute effects of the body scan has produced
significant, if modest, results for the efficacy of the technique on ratings of desire for
a cigarette and withdrawal symptoms. For example, in a sample of temporarily
abstinent smokers, Cropley, Ussher and Charitou (2007) report that compared with an
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control audio, the body scan reduced ratings of desire to smoke and withdrawal
symptoms up to 5-minutes post-task, while Ussher et al (2009) found that in the
laboratory environment, desire to smoke was reduced up to 30 minutes post task for
the body scan group compared with controls. The results of studies one and three are
comparable to these existing findings, and support the efficacy of the body scan for
relieving the desire to smoke for up to 10 minutes and withdrawal symptoms for up to
30 minutes. Again whilst these effects are relatively modest, the average craving
episode only lasts approximately 16.29 minutes (Shiffman, et al, 1997), so the effects
of the body scan may be sufficient to enable smokers to resist the urge for a cigarette
long enough to overcome the episode. The idea that the body scan can potentially help
smokers cope with short craving episodes is particularly attractive in the wake of
legislation making it illegal to smoke within the workplace and enclosed public
spaces. With increasing restrictions on areas where smoking is possible, an easy to
use audio delivered guided body scan routine may provide smokers with the relief
they require until they are in a position to smoke again.
That the body scan is an effective, easy and cheap to administer smoking intervention
is particularly appealing in light of recent statistics showing that by mid-2016, 71% of
UK adults owned a smart phone (The Office of Communications; OFCOM, 2016).
This means that smokers could download a body scan audio file to their smart phone
(or iPod) for use whenever a craving episode occurs. A further benefit of this mode of
intervention delivery is that with the use of earphones, the body scan could be used
wherever an individual is when experiencing a strong craving without anybody
around them being aware (e.g. on public transport). With the prevalence of mobile
smart technology increasing, the future of smoking cessation interventions is more
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likely than ever to involve on-line content rather than face-to-face contact. For
example, a content analysis of 98 Android and iPhone apps for smoking cessation by
Abroms, Lee Westmaas, Bontemps-Jones, Ramani and Mellerson (2013) found that
the Android apps alone were downloaded over 1.2 million times per month
worldwide. However, they also report that adherence to the programmes was very
low, and none of the apps recommended calling a quit-line and only a few
recommended the use of approved cessation medications. This led the authors to
conclude that the apps currently lacked many of the essential elements recommended
for supporting successful cessation, and that they could be vastly improved via better
alignment with evidence based clinical practice guidelines.
So far, only one pilot study by Bricker, Mull, Kientz, Vilardaga, Mercer, Akioka and
Heffner (2014) has examined the feasibility and efficacy of a smartphone app for
smoking cessation using a mindfulness based intervention. They randomly assigned
196 smokers who wished to quit, to receive either an 8 week app based Acceptance
and Commitment intervention (ACT; see chapters two and three for a full
description), or a National Cancer Institute ‘Quit Guide’ comparison app containing
content and structure directly based on the most accessed cessation website in the
world, Smokefree.gov. In terms of adherence, they state that the ACT participants
self-reported opening their app on average 37 times across the course of the study
compared with only 15 times for the ‘Quit Guide’ group, and final abstinence rates
measured by 30-day point prevalence at two months were 13% in the ACT group
versus 8% in the ‘Quite Guide’ group. A major limitation of the study however was
that it didn’t involve a large enough sample to detect a statistically significant
difference, and a much longer follow-up period is required to explore it’s long term
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efficacy in light of the substantial relapse rates that occur up to 12 months post-quit
(Stead et al, 2013). Despite being a pilot study, the results do suggest that mindfulness
based cessation interventions are both feasible and show promising levels of efficacy
compared with other popular cessation apps, and more research into the best methods
of delivering app based interventions is required.
Another important factor to consider when assessing the feasibility of the body scan is
it’s perceived credibility and efficacy as a strategy for the management of cravings.
Study three of this thesis found that there was a significant association between
ratings of enjoyment and both usefulness and effectiveness, and this suggests that it
may only be those who enjoy mindfulness type interventions that are likely to
continue using it in the longer term. In line with this theory, a study by van den Hurk,
Wingens, Giommi, Barendregt, Speckens and van Schie (2011) examined at the
relationship between personality and mindfulness practice by comparing the results of
experienced and meditation naïve participants on the revised NEO Five Factor
Inventory (NEO-FFI; Costa & McCrae, 1992) personality questionnaire and the
Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith & Allen, 2004)
questionnaire. They found that the practice of mindfulness meditation was positively
associated with the personality traits of openness to experience and extraversion and
negatively associated with neuroticism and conscientiousness. Whilst there is no
indication of directionality of the relationship, it could suggest that those scoring
higher on openness are more attracted to the ideas of mindfulness, and therefore more
likely to initiate or maintain practice of mindfulness based interventions. A systematic
review by Katz & Toner (2013) also explored the existence of gender differences in
the effectiveness of mindfulness treatments for substance use disorders. Whilst there
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were only a handful of studies that included participant gender as a variable, there was
evidence that women gravitated towards mindfulness based therapy more than men,
and that they also appeared to benefit more from mindfulness interventions. Again,
more research into the factors which may attract certain demographics to mindfulness
based interventions would further our understanding of how best to integrate them
into cessation programmes and identify those most at risk of non-adherence.
Understanding the target population of smokers is also important, with the findings of
the HSCIC (2014) report stating that those most likely to smoke are unemployed,
male and aged between 20 and 34 (see chapter 1 for a full summary) - a demographic
that may not be typical of those who would normally seek a mindfulness class. In line
with this, smoking has increasingly become a problem associated with low socio-
economic status (SES; Hiscock, Bauld, Amos, Fidler & Munafò, 2012), and even
when this demographic are successfully enrolled in health interventions, attrition rates
are notoriously high and compliance relatively low (Matthews, Chatfield & Brayne,
2006). An RCT of mindfulness training directed at smokers from a disadvantaged
population by Davis et al (2014a) found that pre-intervention attrition was 43% in the
mindfulness group and 37% in controls. This is particularly disappointing, as despite
no significant difference in abstinence rates between the groups in an intent-to-treat
analysis, treatment initiators in the mindfulness group were significantly more likely
to be smoke free at the 24 week follow-up point compared with controls. The most
commonly reported reasons for dropping out were a lack of phone, impermanent
housing or transportation issues, showing how difficulties affecting the everyday lives
of low SES individuals have a significant impact on their ability to remain in this type
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of long-term intervention, and presents a major hurdle for delivering interventions to
those who require it most.
Whilst it is clear that an 8-week mindfulness programme may not be an ideal format
for helping the most vulnerable individuals to quit smoking, a brief body scan
intervention or suitable distraction task may be more appealing to the 20 to 34 year
old male smoker. Research shows that whilst this demographic are more likely to
make a quit attempt than older adults (Dube, McClave, James, Caraballo, Kaufmann
& Pechacek, 2010), they are less likely to use medication or seek medical assistance
(Solberg, Boyle, McCarty, Asche & Thoele, 2007). The results of study three of this
thesis indicated that both the body scan and distraction tasks were effective in
reducing withdrawal symptoms and reducing cravings, and may represent a more
appealing strategy for managing the negative consequences of abstinence during a
quit attempt without the need to seek medical advice. Furthermore, with smartphone
ownership by 16 to 34 year olds in the UK rising to around 90% in 2016 (Statista,
2017), the speed, ease of use and scope for variability in task type depending on
whether the individual prefers to listen to music, a relaxation script or play a game
could provide an more accessible intervention even in hard to reach groups of
smokers.
7.5 Limitations
7.5.1 Measurement issues
Research by Perkins, Briski, Fonte, Scott and Lerman (2009) has shown that the
severity of tobacco abstinence symptoms varies by time of day. For example, they
report that there was a significant effect of time of day during abstinence on self-
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reported levels of cravings, with less craving in the morning compared with other
times of the day. This finding is particularly significant in relation to the studies one
and three of this thesis where baseline levels of desire for a cigarette and withdrawal
symptoms were taken at 10am. The design of the studies relied on craving levels
being sufficiently raised to effectively test the interventions, however question four of
the FTND (in both studies) showed that most participants reported that the first
cigarette of the day was not the one they would most hate to give up. Furthermore,
anecdotally many students reported that they wouldn’t normally smoke until the
afternoon or evening anyway. This highlights the issue of using a high proportion of
students in the study sample (58% in study one and 72% in study three), who are
typically ‘light’ opportunistic smokers (Okuyemi, Harris, Scheibmeir, Choi, Powell &
Ahluwalia, 2002) with erratic sleep wake cycles that consequently impact on their
smoking habits and craving patterns (Lund, Reider, Whiting & Prichard, 2010).
Future research would benefit from both a more ecologically valid sample of smokers,
and intervention testing during different times of the day.
Perkins et al (2009) also found that compared with a placebo patch, wearing a
nicotine patch alleviated negative affect to a greater degree during the evening versus
the morning or afternoon. Combined with the relatively low levels of baseline craving
and withdrawal (reported at 10am), this may account for the lack of significant
difference between ratings given by those wearing a nicotine patch and placebo patch
in study one of this thesis, as neither patch were particularly effective in reducing
cravings or tobacco withdrawal symptoms. Issues relating to the use of a placebo
controlled design are further highlighted by Perkins, Sayette, Conklin and Caggiula
(2002), who discuss the importance of environmental cues, verbal instructions and
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response expectancy in determining the strength of the placebo/anti-placebo effect in
nicotine and tobacco based studies. They argue that a person who believes they are
wearing an inactive placebo patch will respond as if they were not receiving nicotine
(irrespective of drug presence or absence), and that these response expectancies can
reduce or prevent normal responses to receiving nicotine. Despite informing
participants in study one of their equal chance of being allocated to either patch
condition, an underestimation of the potential magnitude of an anti-placebo response
in the experimental arm resulted in a lack of efficacy of the NRT patches, and
emphasises the need for future research to both assess and verify stimulus and
response expectancies when using a placebo controlled design.
The frequency of smoking related thoughts has been found to be a significant barrier
to remaining abstinent (Herd, Boreland & Hyland, 2009), with the suppression of
intrusive thoughts reported as a common technique used by individuals trying to
control cravings (Erskine, Georgiou & Kvavilashvili, 2010). Despite being a widely
used measurement procedure within the field of smoking interventions, the number of
times participants were asked to rate their cravings and withdrawal symptoms in
studies one and three of this thesis may have inadvertently led to an increase in
ratings. For example, asking participants to make ratings immediately after the
intervention was complete could have had the paradoxical effect of halting any
therapeutic benefit of the body scan (or distraction) by forcing them to suddenly
refocus their attention on any underlying cravings or feelings of withdrawal.
Furthermore, asking the same questions repeatedly up to 30 minutes post-intervention
could also have exacerbated cravings, and may also explain why there was often a
plateauing or drop in the final ratings given, as participants anticipated being able to
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smoke again. However, as discussed by Shiffman, West and Gilbert (2004), objective
measures of craving and withdrawal are technically challenging with poor sensitivity
to short-term changes, therefore until advances are made in the development of more
robust measures, the use of self-reporting is currently still the best available option,
although the number of rating requests should be minimized where possible.
The efficacy of the body scan as a therapeutic intervention also to some extent relies
on an individual’s ability to perform visual mental imagery. Participants are guided
through a series of instructions to focus their attention on both the breath and bodily
sensations moving from head to toe, and individual differences in how effective
people are at performing this type of task will have an impact on how useful the body
scan is in a therapeutic context – irrespective of the underlying mechanisms. The
notion that individuals differ in their ability to use mental imagery was first
scientifically tested and reported by Galton (1883), with more modern research by
Poltrock and Brown (1984) identifying individual variability in both image quality
and image processing efficiency. By combining the results from participant responses
on the Vividness of Visual Imagery questionnaire (VVIQ; Marks, 1973) with
performance on a series of spatial tasks, they used factor analysis to identify the single
factor they labeled ‘Visualization ability’. Research by Cui, Jeter, Yang, Montague
and Eagleman (2007) has also found that subjective ratings of individual variability in
imagery vividness accurately correlated with fMRI measured blood flow in the visual
cortex relative to whole brain activity. This suggests that simply asking participants to
rate how well they were able to visualise the breath and sensations in each body part,
may provide an useful insight into whether the body scan was more effective in
negating cravings and withdrawal in those with better visualisation skills.
193
Furthermore, this may also serve as a crude measurement of compliance with the
body scan instructions, as it is not possible to ascertain how actively engaged
participants were with the instructions – especially in study 1 where the intervention
took place outside of a controlled laboratory environment. Also, despite attempting to
comply with the body scan instructions, those with lower imagery abilities may have
had difficulty in actually achieving this. Future studies involving the body scan would
definitely benefit from the introduction of a measurement of imagery ability such as
the VVIQ (Marks, 1973).
7.5.2 Theoretical intervention issues
It has become apparent through the evolution of this thesis that ‘mindfulness’ is a way
of being and thinking in everyday life and requires training and practice, so to extract
the body scan element from the mindfulness pedagogy and condense it into a 10-
minute intervention renders it more akin to a cognitive distraction task than a
mindfulness intervention. Mindfulness practice is meant to foster the opposite of
distraction by encouraging focused attention and acceptance, irrespective of the
positive or negative content of thoughts and feelings (Mrazek, Smallwood &
Schooler, 2012). It is not however plausible that a 10-minute intervention can have
any lasting impact on attention control or emotional volatility without continued
instruction and repeated use. The following quote by Jon Kabat-Zinn (2003) sums up
the way in which the body scan has been extracted from the wider field of
mindfulness theory, and consequently how far removed it has become from it’s
original intention:
“It becomes critically important that those persons coming to the field with
194
professional interest and enthusiasm recognize the unique qualities and
characteristics of mindfulness as a meditative practice...so that mindfulness is
not simply seized upon as the next promising cognitive behavioral technique or
exercise, decontextualized, and “plugged” into a behaviorist paradigm with the
aim of driving desirable change, or of fixing what is broken” (p. 145).
Despite this decontextualisation, the results of previous research and the current thesis
have shown that there are significant benefits in harnessing the ability of a 10-minute
guided body scan routine to alleviate the negative consequences of tobacco
abstinence. This is the case irrespective of whether the underlying mechanisms
originate from distraction, a relaxation response or reduced negative affect, although
when used in this context, any allusion to mindfulness mechanisms is not justified.
7.6 Future research
Currently, only one study has used the body scan as a core element of a smoking
cessation programme (Al-Chalabi et al, 2008), with the results showing no significant
difference in abstinence, intensity of withdrawal symptoms or urge to smoke between
the intervention group and control group. The study did however suffer from serious
methodological issues that had a deleterious impact on results, as the authors report
that staff members at the clinic were not trained to encourage the use of the body
scan, and consequently only 6 out of 20 participants actually downloaded the body
scan intervention file. This effectively meant that the majority of the intervention
group received exactly the same treatment as the control group (behavioural support
and NRT), and resulted in the favouring of the control arm of the study. This
195
highlights the need for future cessation studies focusing on the body scan as a core
strategy in order to effectively test its credibility in a clinical setting.
A further factor to consider when using the body scan as part of a longer-term
cessation programme is whether the positive effects would continue with repeated
usage once the novelty factor may have worn off. There are a number of possible
outcomes of repeated use: continued practice might result in the cultivation of genuine
mindfulness skills such as the acceptance of cravings and withdrawal with mindful
non-judgmental awareness, improved attention control and reduced emotional
reactivity. Alternatively, the novelty factor might wear off and continued use of the
body scan would cease to have any efficacy in relation to cravings and withdrawal
symptoms. The listener may simply ‘zone out’ of the audio narrative and resort to
mind-wandering, which has been shown to be less effective in reducing smoking
related thoughts than engaging with the body scan (May et al, 2012).
Establishing the level of engagement with the audio files leads on to another area that
needs further clarification in terms of the underlying mechanisms. The results of study
three suggested that loading of the limited capacity working memory was a critical
factor in determining the efficacy of the distraction tasks, and not necessarily sensory
modality as argued by the EI theory of desire (Kavanagh et al, 2005). In order to
explore the differing level of demand placed on each sensory modality, it is important
that future research ascertains just how much overlap there is in the employment of
both the phonological loop and visuo-spatial sketchpad as a result of performing the
body scan compared with other distraction tasks. It is possible that despite primarily
being an audio delivered intervention, the instructions to focus on the breath moving
196
through different areas of the body also engages an element of visual imagery. Future
studies aiming to manipulate the level of sensory modality use during the body scan,
or simply inviting participant feedback on their use of visual imagery would be
valuable.
7.7 Conclusions
To conclude, the aim of this thesis was two-fold: to investigate the effects of
combining a guided body scan routine with traditional nicotine replacement therapy,
and to explore the theory that cognitive distraction is the underlying mechanism
responsible for reducing ratings of desire for a cigarette and tobacco withdrawal
symptoms. Overall, the results from studies one and three indicated that the body scan
was effective in reducing the desire to smoke up to 10 minutes post-intervention, and
withdrawal symptoms up to 30 minutes post-intervention. The findings of study one
however indicated that there was no significant difference in any of the ratings
according to whether participants were wearing a nicotine patch versus a placebo
(both were ineffective), or whether they listened to the guided body scan versus a
control audio (both were effective). This led to the theory that rather than harnessing
any of the mindfulness facets associated with the non-judgemental acceptance of
thoughts and feelings, a standalone body scan intervention acted more as a form of
cognitive distraction from smoking related ruminations. Consequently, study two
constituted an exploration of distraction as a construct with the aim of selecting two
appropriate distraction tasks to compare to the body scan on measures craving and
withdrawal. If distraction was indeed a mechanism of the body scan, then it was
hypothesised that all three interventions would produce comparable effects. The
results of study three indicated that whilst all three tasks were effective in reducing
197
withdrawal symptoms, the body scan was superior to the two distraction tasks in
reducing the desire to smoke. This suggested that whilst withdrawal might be
vulnerable to disruption via cognitive distraction, the desire for a cigarette is less
susceptible. It also implied that although cognitive distraction may be partly
responsible for the positive effects observed, the body scan appears to provide
additional benefits over the distraction tasks in terms of moderating the desire to
smoke. Research proposes that the most likely source of these benefits stem from the
regulation of negative affect or a relaxation response.
198
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Appendix 1 – Study 1: MHRA clinical trials approval
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Appendix 2 – Study 1: Ethics Approval
236
Sally GillisonDept of PsychologyFAHSA5
Ethics Committee
01 May 2008
Dear Sally
Investigation to explore whether there is a synergistic effect between nicotine replacement therapy (NRT) and guided bodyscanning on cigarette cravings and withdrawal symptomsEC/2008/21/FAHS
On behalf of the Ethics Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the submitted protocol and supporting documentation.
Date of confirmation of ethical opinion: 1 May 2008.
The final list of documents reviewed by the Committee is as follows:
Document DateSummary of project 1 May
2008Detailed protocol 1 May
2008Information sheet 1 May
2008Consent form 1 May
2008Questionnaire/Interview schedule 1 May
2008
This opinion is given on the understanding that you will comply with the University's Ethical Guidelines for Teaching and Research.
The Committee should be notified of any amendments to the protocol, any adverse reactions suffered by research participants, and if the study is terminated earlier than expected with reasons.
You are asked to note that a further submission to the Ethics Committee will be required in the event that the study is not completed within five years of the above date.
Please inform me when the research has been completed.
Yours sincerely
Aimee Cox (Miss)Secretary, University Ethics Committee
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Registry
cc: Professor T Desombre, Chairman, Ethics CommitteeDr D Lovell & Dr Young
Appendix 3 – Study 1: Poster Advertisement
Are you a
Volunteers are needed to participate in a study looking at new ways to reduce
cigarette cravings.
This will involve a 15 minute session at the office or in another convenient location.
In addition, there will be two sessions of 5 to 10 minutes each. Again, these can be at the office or another convenient location.
A payment of £10 will be made to cover any inconvenience and expenses.
For more information without obligation, please call Sally on:
07815 ****** or email [email protected] (I will call you back)
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Department of Psychology, University of Surrey, Guildford, GU2 5XH
This study has been reviewed and has been given a favourable ethical opinion by the University of Surrey Ethics
Committee
Appendix 4 – Study 1: Guided body scan routine verbatim narrative
The following meditation is called a body scan meditation, which is a form of
mindfulness meditation. It can help you become more familiar with your body, work
effectively with body sensation, and feeling of discomfort, stress and pain. It also will
help you to cultivate your powers of concentration. The key to using this meditation
effectively is to simply notice what is present in the current moment. Sensations,
moods, thoughts and feelings will arise and fall. Just simply notice without the need to
attach.
As you go through the practice, try to focus clearly on each area of the body, noticing
whatever feelings or sensations arise. If at any time during the meditation you find
that you’ve become distracted, lost in thought, focused on a memory, or something
that needs to be done, simply let go of that distraction and return your full and
complete attention to the meditation where you left off.
Now let’s begin.
Sit in a comfortable meditation posture and gently allow your eyes to close. Become
aware of your body. Begin to notice the feeling of the weight and the density of your
body as you sit in the chair or sit on the floor, and then bring your attention to the
natural flow of your breath. Notice that as you inhale, your stomach gently rises, and
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as you exhale, your stomach gently contracts. This type of breathing is completely
effortless. Notice the effortlessness of diaphragmatic breathing.
And now I’d like you to follow the full path of the breath, feel the breath as it enters
through your nostrils, crosses your palate to the back of your throat. Feel your lungs
expand and then feel your stomach rise. Notice there’s a slight pause between the
inhale and the exhale. And then follow the breath on the exhale, simply noticing,
simply paying attention.
If thoughts come in to your mind, simply refocus on the breath. And now gently bring
your attention to the very top of your head, the crown chakra. Notice any sensations
you feel at the very top of your head, not trying to change or fix or alter your body in
any way, just become aware. Then slowly move your attention down to your
forehead, again noticing any sensations or feelings. Then become aware of the eyes,
the cheeks, your jaw and tongue, and become aware of the throat and neck.
And now bring you attention gently to the shoulders, noticing any feelings that arise.
And move your attention to the arms, the hands, and then finally the fingers. Just
noticing any sensations, any feelings.
And now gently bring your awareness to the front of the body, to the chest, the rib
cage, the lungs and the abdomen. You may begin to sense your own heartbeat. You
may begin to notice the rise and fall of each breath.
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And now gently shift your attention to the back of the body. Notice the feeling of your
spine. Move your awareness to your shoulder blades, your middle back, and then
finally the lumbar region of the lower back, again noticing any sensations that arise,
just feeling your own body.
And now gently move your attention to your seat, your waist and hips, the pelvis. And
then slowly move your attention to your legs and thighs, your hamstrings, and down
to your knees. And slowly being your attention to your calves and shins, again
noticing any sensation that may arise. Move your attention now down to your feet, the
arches, the heels, the balls of the feet. Notice the feeling of your feet as they touch the
floor. And then bring your attention to the toes, noticing any sensations that may
arise, notice any tingling or the temperature of the toes.
And then finally bring attention to the entire body as a whole system. Try to become
fully present with your entire body. As you become fully present with your entire
body, allow yourself to feel completely relaxed, yet maintain your full attention to the
present moment.
When you feel ready, slowly being to wiggle your fingers and toes, and then gently
allow your eyes to open. Try to maintain this feeling of being fully connected to the
present moment.
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Appendix 5: Fagerström Test for Nicotine Dependence (FTND; Heatherton et al, 1991)
Please answer the following questions about your smoking:
(F1) How many cigarettes per day do you usually smoke?
(circle one response) 10 or less 011 to 20 120 to 30 231 or more 3
(F2) How soon after you wake up do you smoke your first cigarette?
(circle one response) Within 5 minutes 36-30 minutes 231 or more 1
(F3) Do you find it difficult to stop smoking in no-smoking areas?
(circle one response) NO 0YES 1
(F4) Which cigarette would you most hate to give up?
(circle one response) The first in the morning 1Another 0
(F5) Do you smoke more frequently in the first hours after waking than during the rest of the day?
(circle one response) NO 0YES 1
(F6) Do you smoke if you are so ill that you are in bed most of the day?
(circle one response) NO 0YES 1
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Level of Nicotine Dependence:0 – 2 Very Low3 – 4 Low5 Moderate6 – 7 High8 – 10 Very High
243
Appendix 6: Mood and Physical Symptoms Scale (MPSS; West & Hajek, 2004)
Not at all Slightly Somewhat Very Much Extremely
How irritable do you feel right now?1 2 3 4 5
How depressed do you feel right now?1 2 3 4 5
How tense do you feel right now?1 2 3 4 5
How restless do you feel right now?1 2 3 4 5
How difficult do you find it to concentrate right now?1 2 3 4 5
How stressed do you feel right now?1 2 3 4 5
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Appendix 7 – Study 1: Participant information sheet
You are being invited to take part in a research study. Before you decide to take part it is important that you understand why the research is being done and what it will involve. Please take time to carefully read the following information and ask if anything is not clear.
What is the purpose of the study?The main aim of this research study is to examine how your cravings for cigarettes change following the administration of a nicotine or placebo patch combined with 10 minutes of scanning different body areas, or 10 minutes of listening to someone reading a passage of text.
What is bodyscanning?Stemming from Buddhist meditation, bodyscanning uses the technique of mindfulness, which encourages you to pay attention on purpose, in the present moment, to your unfolding experience moment by moment. You will be asked to relax, concentrate on your breathing, and focus your attention on the sensations in five different areas of the body: hands and forearms, upper arms and shoulders, chest and back, upper legs, and lower legs and feet.
What will you be asked to do?You will be asked to attend a total of three assessments for a total of around 30 minutes. These can either be at your place of work or, another convenient location. The first visit will take about 10 minutes and involve checking how much you smoke and asking a few background questions. You will then be asked not to smoke at all, or use any other nicotine based product from 10pm that evening until you have completed the experiment the following day. This is essential for the study. At the second assessment the following day, you will be seen at approximately 10am for about 15 minutes. Initially, you will be asked to blow into a machine that will confirm that you have not smoked. You will then be given a Palmtop computer which is programmed with a questionnaire asking you to rate your cigarette cravings and mood, and issued with a nicotine or placebo patch by the researcher. At this point you will also be given an MP3 player containing the audio recording appropriate to your condition (body scan or reading), and asked to go back to your natural environment. You have an equal chance of being allocated to any one of the four conditions. An hour later, the Palmtop will ‘beep’, turn itself back on, and ask you to rate your cigarette cravings and mood again. This will happen again in another hour, but this time you will also be required to listen to the 10 minute audio recording on the MP3, asking you to focus your attention on different body areas, or to sit quietly and listen to a passage of text being read. You will then be asked to rate your cravings and mood again 5, 10, 20 and 30 minutes later. You will be asked not to smoke even a single puff of a cigarette until you attend a final five minute assessment. Approximately three hours after the previous assessment you will be asked to return the palmtop, your smoking abstinence will be confirmed, you will be paid £10 (towards your travel expenses and to thank you for your time) and you will be free to smoke. You will only be paid £10 if you attend all three assessments and you are confirmed as having not smoked at the final visit.
Are there any risks involved with taking part in the study? There are no known risks of taking part in the study.
Are you eligible to join the study?You are eligible to take part in the study if you are aged 18 to 65 years, you have smoked 10 or more
cigarettes a day for at least three years and you are not pregnant or receiving treatment for a mental health condition. All information which is collected during the course of the research will be kept strictly confidential. If you decide to take part you will be given this information sheet to keep and you will be asked to sign a consent form, which you will keep. You will be free to withdraw from the study at any time and without giving a reason. Thank you for taking the time to read this information sheet. If you
245
have any queries or concerns please phone Sally on 07815 ****** or e-mail: [email protected] who will do her best to answer your questions.
Appendix 8 – Study 1: Participant consent form
I the undersigned agree to take part in the smoking intervention study.
I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.
I agree to comply with any instruction given to me during the study and to co-operate fully with the investigators. I shall inform them immediately if I suffer any deterioration of any kind in my health or well-being, or experience any unexpected or unusual symptoms.
I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.
I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.
I acknowledge that in consideration for completing the study I shall receive the sum of £10.00.
I recognise that the sum would be less, and at the discretion of the Principal Investigator, if I withdraw before completion of the study, fail to adhere to the period of smoking abstinence, or fail to return any equipment used in the study.
I understand that in the event of my suffering a significant and enduring injury (including illness or disease) as a direct result of my participation in the study, compensation will be paid to me by the, subject to certain provisos and limitations. The amount of compensation will be appropriate to the nature, severity and persistence of the injury and will, in general terms, be consistent with the amount of damages commonly awarded for similar injury by an English court in cases where the liability has been admitted
I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.
Name of volunteer (BLOCK CAPITALS) ......................................................
Signed ......................................................
Date ...................................
Name of researcher/person taking consent (BLOCK CAPITALS) ......................................
246
Signed ..................................................
Date ...................................
Appendix 9 – Study 1 & 3: Demographics questionnaire
How old are you? I am …………years
Are you Male or Female (please circle)
What is your ethnic group? (please tick one box only)WhiteBlack AfricanBlack CaribbeanAny other Black backgroundWhite & Black CaribbeanWhite & Black AfricanWhite & AsianAny other mixed backgroundIndianBangladeshiPakistaniAny other Asian backgroundChineseAny other ethnic group
What is your current marital status? (please tick one box only)Single (never married) living aloneSingle (never married) living with partnerMarriedDivorcedWidowedSeparated
What is your usual occupation? (please tick one box only)Professional/managerClerical/secretarialSkilled manualUnskilled/semi-skilled manualHome keeper/makerStudent
Would you like to give up smoking? …………….YES/NO (circle response)
247
For how many years have you been smoking? ………..years
How many serious quit attempts have you made in the last year? ………..attempts
248
Appendix 10 – Study 1: Rating interval schedule
Ratings will be prompted at approximately:
1. 10am – Single set of ratings in the presence of the researcher.
2. 11am – Single set of ratings in your natural environment.
3. 12pm – Multiple rating at the intervals detailed below.
Times ratings occur when listening to the audio recording:
The Palmtop will record the time at which the ratings were made.
Please do not take vigorous exercise or alcohol or to do anything outside of your normal routine before you have fully completed the study.
Call me after you have made the final ratings on the palmtop (07815 ******)
Rating 1(Just before audio)
Rating 2 (Just after)
Rating 5 (20 mins after)
Rating 3(5 mins after)
Rating 6 (30 mins after)
Audio (10 mins)
Rating 4 (10 mins after)
249
Appendix 11 – Study 1: Participant feedback sheet
For these three questions please circle one response only:
How useful did you find the intervention for relieving your desire to smoke?
Not at alluseful
Slightlyuseful
Moderatelyuseful
VeryUseful
ExtremelyUseful
Would you recommend this strategy to smokers who are trying to quit?
Definitely would not
recommend
Probablywould not
recommendNot sure
Probably would
recommend
Definitely would
recommend
How effective do you think this strategy would be for most smokers?
Not at all effective
Slightly effective
Moderately effective
Veryeffective
Extremely effective
250
Appendix 12 – Study 2: Ethics Approval
251
Appendix 13 - Study 2: Distraction task systematic literature search grid
Table 1
Distraction task systematic search results arranged by publication year
Author(s) Year No of P's
Cohort Strategy Strategy Classification
Title Source
Forster, S., Robertson, D.J., Jennings, A., Asherson, P. & Lavie, N.
2014 34 Adults (ADHD) & matched controls
Letter search task Visual Task Plugging the attention deficit: Perceptual load counters increased distraction in ADHD.
Neuropsychology, 28(1), 91-97.
Pacheco-Unguetti, A.P. & Parmentier, F.B.R.
2014 40 Students Auditory-visual oddball task in which visual digits are categorised while ignoring task-irrelevant sounds
Audio-visual Task Sadness increases distraction by auditory deviant stimuli.
Emotion, 14(1), 203-213.
Sil, S., Dahlquist, L.M., Thompson, C., Hahn, A., Herbert, L., Wohlheiter, K. & Horn, S.
2014 62 Children (6-13 yrs) Interactive videogame distraction was delivered both with and without a VR helmet
Virtual Reality The effects of coping style on virtual reality enhanced videogame distraction in children undergoing cold pressor pain
Journal of Behavioral Medicine, 37(1), 156-165.
Kohl, A., Rief, W. & Glombiewski, J.A.
2013 109 Students (Female) Asked to imagine a pleasant scene Mental Imagery Acceptance, cognitive restructuring, and distraction as coping strategies for acute pain.
The Journal of Pain, 14(3), 305-315.
Woodruff, C.C. & Klein, S.
2013 ? ? Mental imagery distraction and word generation distraction. Mental Imagery / Word Task
Attentional distraction, μ-suppression and empathic perspective-taking
Experimental Brain Research, 229(4), 507-515.
Sil, S., Dahlquist, L.M. & Burns, A.J.
2013 1 Child (4yrs) Videogame distraction: Go Diego Go! Safari Rescue videogame on the Wii
Games (electronic) Case study: Videogame distraction reduces behavioral distress in a preschool-aged child undergoing repeated burn dressing changes: A single-subject design.
Journal of Pediatric Psychology, 38(3), 330-341.
Hooper, N. & McHugh, L.
2013 74 Students Thought distraction: Instructed to suppress negative thoughts & replace them with good thoughts.
Mental Imagery Cognitive defusion versus thought distraction in the mitigation of learned helplessness.
The Psychological Record, 63(1), 209-218.
Ogden, J., Coop, N., Cousins, C., Crump, R., Field, L., Hughes, S. & Woodger, N.
2013 81 Adults (Female) Driving simulation, television viewing, social interaction Driving Task/Visual Task/Talking
Distraction, the desire to eat and food intake. Towards an expanded model of mindless eating.
Appetite, 62, 119-126.
Wohlheiter, K.A. & Dahlquist, L.M.
2013 65 Children (3-6 yrs) Playing a video game (interactive distraction), or watching a video game (passive distraction) V-Smile game: ‘‘Journey to Paradise Falls" a game on the Up! V-Smile Smartridge
Games (electronic) Interactive Versus Passive Distraction for Acute Pain Management in Young Children: The Role of Selective Attention and Development
Journal of Pediatric Psychology, 38(2), 202-212.
Wahl, K., Huelle, J.O., Zurowski, B. &
2013 30 Adults (OCD Patients)
Silently counting backwards in sevens Number Task Managing obsessive thoughts during brief exposure: An experimental study
Cognitive Therapy and Research, 37(4), 752-761.
247
Kordon, A. comparing mindfulness-based strategies and distraction in obsessive–compulsive disorder
Stafford, L.D., Agobiani, E. & Fernandes, M.
2013 54 Adults Listening to contemporary club music & shadowing task of listening to a reading of a news article from the BBC news.
Auditory Task Perception of alcohol strength impaired by low and high volume distraction.
Food Quality and Preference, 28(2), 470-474.
Marek, R.J., Ben-Porath, D.D., Federici, A., Wisniewski, L. & Warren, M.
2013 17 Adults (Females with an Eating Disorder)
Word searches Word Task Targeting premeal anxiety in eating disordered clients and normal controls: A preliminary investigation into the use of mindful eating vs. distraction during food exposure.
International Journal of Eating Disorders, 46(6), 582-585.
Van Ryckeghem, D.M. L., Crombez, G., Van Hulle, L. & Van Damme, S.
2012 53 Students Detect a visual target (a small dot) as quickly as possible after the presentation of a word pair & detect a visual target (a small dot), which was preceded by coloured cues at the same (valid) or opposite (invalid) spatial location.
Visual Task Attentional bias towards pain-related information diminishes the efficacy of distraction.
Pain, 153(12), 2345-2351.
Inal, S. & Kelleci, M. 2012 123 Children (6-12yrs) Looked through distraction cards (Flippits®), which consist of various eye-catching pictures and shapes.
Visual Task Distracting children during blood draw: Looking through distraction cards is effective in pain relief of children during blood draw.
International Journal of Nursing Practice, 18(2), 210-219.
Buhle, J.T., Stevens, B.L., Friedman, J.J. & Wager, T.D.
2012 38 Adults 3-back calibration task: viewed a series of letters one at a time & had to say whether they were the same or different from the letter presented 3 trials before.
Visual Task Distraction and placebo: Two separate routes to pain control.
Psychological Science, 23(3), 246-253.
Wohlheiter, K.A. 2012 65 Children (3-6yrs) Played a videogame (active) or watched a videogame (passive) Games (electronic) Distraction for pain management in young children: Understanding the role of selective attention and development.
Dissertation Abstracts International: Section B: The Sciences and Engineering, 72(12-B). 7711.
Blom, J.H.G., Wiering, C.H. & Van der Lubbe, R.H.J.
2012 18 Students Mental-arithmetic or a word-association distraction task Word Task / Number Task
Distraction reduces both early and late electrocutaneous stimulus evoked potentials.
Journal of Psychophysiology, 26(4), 168-177.
Grider, B., Luiselli, J.K. & Turcotte-Shamski, W.
2012 1 Adult (Autistic) Favourite video watching Visual Task Graduated exposure, positive reinforcement, and stimulus distraction in a compliance-with-blood-draw intervention for an adult with autism.
Clinical Case Studies, 11(3), 253-260.
Law, E.F. 2012 79 Children (6-15 yrs) Multi-sensory VR distraction & multi-sensory + cognitive VR distraction
Virtual Reality How does distraction work? Cognitive engagement as a mechanism of virtual reality distraction for children.
Dissertation Abstracts International: Section B: The Sciences and Engineering, 71(7-B), 4502.
Yoon, K.L. & Joormann, J. (2012).
2012 51 Students Focused thoughts on externally oriented and not related to symptoms, emotions, or self (e.g. imagine looking at the shiny surface of a trumpet).
Mental Imagery Is timing everything? Sequential effects of rumination and distraction on interpersonal problem solving.
Cognitive Therapy and Research, 36(3), 165-172.
Zhang, W. & Lu, J. 2012 20 Students Silent-counting and deep-breathing Number Task / Breathing
Late positive potentials of attentional distraction of emotion regulation.
Chinese Journal of Clinical Psychology, 20(6), 773-776.
Griskova-Bulanova, I., Ruksenas, O., Dapsys, K., Maciulis, V. & Arnfred, S.M.
2012 9 Adults Easy distraction: Reading a magazine article; Difficult distraction - searching for Landolt rings
Reading / Visual Task
P50 potential-associated gamma band activity: Modulation by distraction.
Acta Neurobiologiae Experimentalis, 72(1), 102-109.
Verhoeven, K., 2012 81 Children (9-18 yrs) Attention-demanding tone-detection task Auditory Task Pain catastrophizing influences the European Journal of Pain, 16(2), 256-
248
Goubert, L., Jaaniste, T., Van Ryckeghem, D.M.L. & Crombez, G.
use and the effectiveness of distraction in school children.
267.
Villarreal, E.A.G., Brattico, El., Vase, L., Østergaard, L. & Vuust, P.
2012 48 Adults Mental arithmetic (PASAT) Number Task Superior analgesic effect of an active distraction versus pleasant unfamiliar sounds and music: The influence of emotion and cognitive style.
PLoS ONE, 7(1), ArtID: e29397.
Moont, R., Crispel, Y., Lev, R., Pud, D. & Yarnitsky, D.
2012 51 Students (Right Handed Males)
Non-invasive continuous cognitive visual task: 8 shapes in 3 colors; red, green & blue presented against a light gray background, 4 random shapes with random colors were flashed on the screen & participants instructed to concentrate on the ‘computer game’ and mentally count how many circle shapes and square shapes appeared at the same time within a group of four shapes during the time-course of the task.
Visual Task Temporal changes in cortical activation during distraction from pain: A comparative LORETA study with conditioned pain modulation.
Brain Research, 1435, 105-117.
Denson, T.F., Moulds, M.L. & Grisham, J.R.
2012 121 Students Asked to write for 20 minutes on describing "the layout of the UNSW campus as you see it in your mind and how you would describe it to someone who has never been here before. Please write a thorough and detailed description.”
Writing Task The effects of analytical rumination, reappraisal, and distraction on anger experience.
Behavior Therapy, 43(2), 355-364.
Buhle, J. 2012 37 Adults 3-back task: P is presented with a sequence of letters, and had to indicate when the current letter matched the one from 3 steps earlier in the sequence.
Letter Task The neural and psychological constituents of placebo and distraction.
Dissertation Abstracts International: Section B: The Sciences and Engineering, 73(4-B), 2557.
Sil, S. 2012 62 Children (6-13 yrs) Virtual reality videogame Virtual Reality Virtual reality enhanced videogame distraction in children undergoing cold pressor pain: The role of coping style and coping strategies
Dissertation Abstracts International: Section B: The Sciences and Engineering, 72(12-B), 7709.
Verhoeven, K., Van Damme, S., Eccleston, C., Van Ryckeghem, D.M.L., Legrain, V. & Crombez, G.
2011 91 Students Attention-demanding tone-detection task Auditory Task Distraction from pain and executive functioning: An experimental investigation of the role of inhibition, task switching and working memory.
European Journal of Pain, 15(8), 866-873.
McMahon, K., Sparrow, B., Chatman, L. & Riddle, T.
2011 146 Students Listen to their own music, solve an anagram puzzle, solve a word search puzzle.
Game (non-electronic)/Music
Driven to distraction: The impact of distracter type on unconscious decision making.
Social Cognition: Special Issue: Unconscious thought, 29(6), 683-698.
Bjerre, L., Andersen, A.T., Hagelskjær, M.T., Ge, N., Mørch, C.D. & Andersen, O.K.
2011 12 Adults Stroop test Visual Task Dynamic tuning of human withdrawal reflex receptive fields during cognitive attention and distraction tasks.
European Journal of Pain, 15(8), 816-821.
Digdon, N. & Koble, A.
2011 41 Students Imagery Distraction: Close their eyes and imagine a situation that is interesting and engaging, but also pleasant and relaxing (such as a holiday, beautiful summer afternoon of leisure, or a special family occasion), but not too arousing (such as a sexual encounter or an exciting sporting event).
Mental Imagery Effects of constructive worry, imagery distraction, and gratitude interventions on sleep quality: A pilot trial.
Psychology: Health and Well-Being, 3(2), 193-206.
Jameson, E., Trevena, 2011 60 Adults Active: Electronic gaming system (Wii game ‘Bubble’); Passive: Games (electronic) / Electronic gaming as pain distraction. Pain Research & Management, 16(1),
249
J. & Swain, N. television (2 mins of animated video series Dragonball Z). Visual Task 27-32.Friedrich, E.V.C., Scherer, R., Sonnleitner, K. & Neuper, C.
2011 12 Adults Word association & mental subtraction. Word Task / Number Task
Impact of auditory distraction on user performance in a brain–computer interface driven by different mental tasks.
Clinical Neurophysiology, 122(10), 2003-2009.
Kristjánsdóttir, Ó. & Kristjánsdóttir, G.
2011 118 Children (14 yrs) Music Listening: chosen from top 10 charts of the day, with the exception of one relaxing classical CD - with & without headphones.
Music Randomized clinical trial of musical distraction with and without headphones for adolescents’ immunization pain.
Scandinavian Journal of Caring Sciences, 25(1), 19-26.
Kocovski, N.L., MacKenzie, M.B. & Rector, N.A.
2011 114 Students Complete an anagram. Word Task Rumination and distraction periods immediately following a speech task: Effect on postevent processing in social anxiety
Cognitive Behaviour Therapy, 40(1), 45-56.
Ruscheweyh, R., Kreusch, A., Albers, C., Sommer, J. & Marziniak, M.
2011 27 Adults (1) Mental imagery (2) Listening to preferred music (3) Spatial discrimination of brush stimuli.
Mental Imagery / Music / Visual Task
The effect of distraction strategies on pain perception and the nociceptive flexor reflex (RIII reflex).
Pain, 152(11), 2662-2671.
Weiss, K.E., Dahlquist, L.M. & Wohlheiter, K
2011 61 Children (3-5 yrs) (1) Interactive distraction: used a joystick to play a developmentally appropriate game ("Balloon Ride" section of the Winnie-the-Pooh V.Smile Smartridge video game) (2) Passive distraction: watched prerecorded game output of same video game segment.
Games (electronic) Playing / Watching
The effects of interactive and passive distraction on cold pressor pain in preschool-aged children.
Journal of Pediatric Psychology, 36(7), 816-826.
McLain, M.K. 2011 80 Adult (Females) Reading a neutral article. Reading The effects of rumination, hostility, and distraction on cardiovascular reactivity and recovery from anger recall in healthy women.
Dissertation Abstracts International: Section B: The Sciences and Engineering, 71(6-B), 3940.
Law, E.F., Dahlquist, L.M., Sil, S., Weiss, K.E., Herbert, L., Wohlheiter, K. & Horn, S.
2011 79 Children (6-15 yrs) (1) Interactive distraction: using voice commands to play a videogame (2) Passive distraction: Watching the output from the same videogame segment (The ‘‘Aqua Garden’’ level of the Nintendo WiiTM ‘‘Nights: Journey of Dreams’’™ videogame.
Virtual Reality Videogame distraction using virtual reality technology for children experiencing cold pressor pain: The role of cognitive processing.
Journal of Pediatric Psychology, 36(1), 84-94.
Silvestrini, N., Piguet, V., Cedraschi, C. & Zentner, M.R.
2011 20 Students Pleasant music: Chose one of 4 pieces of western classical music (Bach, Brandenburg Concertos n°2 and 3, 1st and 3rd movements, Mozart, Eine Kleine Nachtmusik, Allegro and Rondo; or Bizet, Symphony in ut major, 4th movement). Unpleasant music: Dissonant excerpts of contemporary music (Penderecky, Symphony n°1, Dynamis II ; Gyorgy Ligeti, Concerto for Cello and Orchestra; Pierre Boulez, Notations II for Orchestra).
Music Music and auditory distraction reduce pain: Emotional or attentional effects?
Music and Medicine, 3(4), 264-270.
Moont, R., Pud, D., Sprecher, E., Sharvit, G. & Yarnitsky, D.
2010 34 Adults Continuous cognitive visual task: To count how many circle shapes, square shapes and triangle shapes appeared simultaneously within a group of four shapes.
Visual Task Pain inhibits pain’ mechanisms: Is pain modulation simply due to distraction?
Pain, 150(1), 113-120.
Campbell, C.M., Witmer, K., Simango, M., Carteret, A., Loggia, M.L., Campbell, J.N., Haythornthwaite, J.A.
2010 32 Adults Arcade-style video games (Chicken Invaders, Pacman & Bejewelled).
Games (electronic) Catastrophizing delays the analgesic effect of distraction.
Pain, 149(2), 202-207.
250
& Edwards, R.R.Masuda, A., Feinstein, A.B., Wendell, J.W. & Sheehan, S.T.
2010 147 Students Read an emotionally neutral article about the rocks of Stonehenge for 5 minutes.
Reading Cognitive defusion versus thought distraction: A clinical rationale, training, and experiential exercise in altering psychological impacts of negative self-referential thoughts.
Behavior Modification, 34(6), 520-538.
Dahlquist, L.M., Weiss, K.E., Law, E.F., Sil, S., Herbert, L.J., Horn, S.B., Wohlheiter, K. Ackerman, C.S.
2010 50 Children (6-10 yrs) Videogame distraction with & without VR helmet (The Ice Age 2: The Meltdown© “Eviscerator” game).
Games (electronic) / Virtual Reality
Effects of videogame distraction and a virtual reality type head-mounted display helmet on cold pressor pain in young elementary school-aged children.
Journal of Pediatric Psychology, 35(6), 617-625.
Wright, T. & Raudenbush, B.
2010 75 Adults The heavy metal song used in the study was "Drag the Waters" by Pantera, and the classical song used in the study was "Stabat Mater Movement XII, Quando Corpus-Amen" by Giovanni Pergolesi. The videos were played on a computer monitor. The adventure video contained short clips from the Spiderman Trilogy, Terminator 3, Star Wars Episode III, Live Free or Die Hard, the Lord of the Rings Trilogy, Mission Impossible 3, and the Matrix Trilogy. The romantic video contained short clips from the Spiderman Trilogy, How to Lose a Guy in 10 Days, Sleepless in Seattle, Hitch, Stardust, The Wedding Singer, and 50 First Dates.
Music / Video Interaction effects of visual distractions, auditory distractions and age on pain threshold and tolerance.
North American Journal of Psychology, 12(1), 145-158.
Bourne, C., Frasquilho, F., Roth, A.D. & Holmes, E.A.
2010 78 Adults Verbal Interference (counting backwards in threes) and Visuo-spatial tapping.
Number Task / Visuo-spatial Task
Is it mere distraction? Peri-traumatic verbal tasks can increase analogue flashbacks but reduce voluntary memory performance.
Journal of Behavior Therapy and Experimental Psychiatry, 41(3), 316-324.
Alhani, F., Shad, H., Anoosheh, M. & Hajizadeh, E.
2010 42 Adolescents on haemodialysis (10-21 yrs)
Look at two similar pictures and tell the number of differences between them.
Visual Task The effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis.
Pain Management Nursing, 11(2), 85-91.
Masuda, A., Twohig, M.P., Stormo, A.R., Feinstein, A.B., Chou, Y. & Wendell, J.W..
2010 132 Students (1) Asked to say the word “milk” once and to notice all of its perceptual functions (e.g., “white,” “cold,” “creamy”), then not to think of the word “milk” by thinking of something emotionally neutral or less unpleasant for about 20s (2) Reading an emotionally neutral article about Japan (i.e., vacations to the mountains) for 5 min.
Word Task / Reading Task
The effects of cognitive defusion and thought distraction on emotional discomfort and believability of negative self-referential thoughts.
Journal of Behavior Therapy and Experimental Psychiatry, 41(1), 11-17.
Lv, J., Wang, T., Qiu, J., Feng, S., Tu, S. & Wei, D.
2010 14 Students Remember the order of either three digits (low-load condition) or seven digits (high-load condition).
Number Task The electrophysiological effect of working memory load on involuntary attention in an auditory–visual distraction paradigm: An ERP study.
Experimental Brain Research, 205(1), 81-86.
Gutierrez-Martinez, O., Guiterrez-Maldonado, J., Cabas-Hoyos, K. & Loreto, D.
2010 37 Students Virtual reality intervention of a stereoscopic environment named "Surreal World" that involves attention-diverting techniques.
Virtual Reality The illusion of presence influences VR distraction: Effects on cold-pressor pain.
Annual Review of CyberTherapy and Telemedicine: Special Issue: Imaging the future, 8, 123-126.
Strick, M., Holland, R.W., Van Baaran, R.B. & Van
2010 49 Students A simple math problem Number Task The puzzle of joking: Disentangling the cognitive and affective components of humorous distraction.
European Journal of Social Psychology, 40(1), 43-51.
251
Knippenberg, A.D.Dahlquist, L.M., Herbert, L.J., Weiss, K.E. & Jimeno, M.
2010 41 Students P's used a VR head-mounted display helmet, steering wheel & foot pedal to play an auto racing video game.
Virtual Reality Virtual-reality distraction and cold-pressor pain tolerance: Does avatar point of view matter?
Cyberpsychology, Behavior, and Social Networking, 13(5), 587-591.
Tüfekci, F.G, Çelebioğlu, A. & Küçükoğlu, S.
2009 206 Children Looking through kaleidoscopes. Games (non-electronic)
Turkish children loved distraction: Using kaleidoscope to reduce perceived pain during venipuncture
Journal of Clinical Nursing, 18(15), 2180-2186.
Strick, M., Holland, R.W. van Baaren, R.B. & van Knippenberg, A.
2009 90 Students Humorous or equally positive non-humorous stimulus. Humour Finding comfort in a joke: Consolatory effects of humor through cognitive distraction
Emotion, 9(4), 574-578.
Ehring, T., Szeimies, A.K. & Schaffrick, C.
2009 83 Students P's read a transcript of thoughts related to a journey through China, complete an easy computer task to read and think about questions presented on the computer screen and answer them in their mind - i.e. recall as many members of a certain category as they could think of.
Computer Task An experimental analogue study into the role of abstract thinking in trauma-related rumination
Behaviour Research and Therapy, 47(4), 285-293.
Raudenbush, B., Koon, J., Cessna, T. & McCombs, K.
2009 27 Adults Six video game conditions (action, fighting, puzzle, sports, arcade, and boxing) and a nongame control condition.
Games (electronic) Effects of playing video games on pain response during a cold pressor task
Perceptual and Motor Skills, 108(2), 439-448.
Rutter, C.E., Dahlquist, L.M. & Weiss, K.E.
2009 28 Adults Virtual reality. Virtual Reality Sustained efficacy of virtual reality distraction.
The Journal of Pain, 10(4), 391-397.
Zack, M., Sharpley, J., Dent, C.W. & Stacy, A.W.
2009 171 Children (14-16 yrs)
Counting backwards from 200 by two's. Number Task Context effects and false memory for alcohol words in adolescents
Addictive Behaviors, 34(3), 327-330.
Huffziger, S. & Kuehner, C.
2009 76 Depressed patients Distraction: P's concentrates attention for 8 mins on externally focused thoughts ‘‘think about a boat slowly crossing the Atlantic, the expression on the face of the Mona Lisa’’); Mindful self-focus: 28 cards to prompt mindful approach ‘‘realize that all feelings, also negative feelings, are part of human experience’’, ‘‘take note of your thoughts and feelings without judging them’’) and on moment-to-moment awareness (the item ‘‘consciously attend to your breath for some seconds’’).
Mental Imagery Rumination, distraction, and mindful self-focus in depressed patients
Behaviour Research and Therapy, 47(3), 224-230.
Sani, F. & Bennett, M.
2009 120 Children (5, 7 & 10 yrs)
Two minutes of circling all the flowers that could be identified in a detailed picture.
Visual Task Children's inclusion of the group in the self: Evidence from a self–ingroup confusion paradigm
Developmental Psychology, 45(2), 503-510.
Denson, T.F. Fabiansson, E.C. Creswell, J.D. & Pedersen, W.C.
2009 48 Students P's wrote about several neutral topics such as the layout of the local post office, the shape of a large black umbrella, and two birds sitting in a tree.
Memory Task Experimental effects of rumination styles on salivary cortisol responses.
Motivation and Emotion, 33(1), 42-48.
Hoffman, H.G., Patterson, D.R., Soltani, M., Teeley, A., Miller, W. & Shara, S.R.
2009 1 Trauma Patient (Adult)
Immersive virtual reality. Virtual Reality Virtual reality pain control during physical therapy range of motion exercises for a patient with multiple blunt force trauma injuries.
CyberPsychology & Behavior, 12(1), 47-49.
Kosloff, S. & Greenberg, J.
2009 64 Adults Reading 7 page excerpt (4-6 mins) from ‘‘The Growing Stone,” a short story by Albert Camus (1957).
Reading Pearls in the desert: Death reminders provoke immediate derogation of
Journal of Experimental Social Psychology, 45(1), 197-203.
252
extrinsic goals, but delayed inflationDahlquist, L.M., Weiss, K.E., Dillinger Clendaniel, L., Law, E.F., Sonntag Ackerman, C. & McKenna, K.D.
2009 41 Children (6-14 yrs) Underwater virtual environment - p's scuba dive with sea turtles & tropical fish searching for treasure chests. Auditory stimulation mimicked sounds of breathing through scuba equipment.
Virtual Reality Effects of Videogame Distraction using a Virtual Reality Type Head-Mounted Display Helmet on Cold Pressor Pain in Children
Journal of Pediatric Psychology, 34(5), 574-84.
Raudenbush, B., Koon, J., Cessna, T. & McCombs, K.
2009 57 Adults P's played six video game conditions (action, fighting, puzzle, sports, arcade, and boxing) and a nongame control condition.
Games (electronic) Effects of playing video games on pain response during a cold pressor task.
Perception & Motor Skills, 108(2), 439-448.
Kwekkeboom, K.L. Bumpus, M., Wanta, B.S & Ronald, C.
2008 724 Oncology Nurses Music, guided imagery, relaxation, distraction. Music / Mental Imagery
Oncology nurses' use of nondrug pain interventions in practice
Journal of Pain and Symptom Management, 35(1), 83-94.
Sheppes, G. & Meiran, N.
2008 46 Students P's asked to think about something unrelated to the film content (Holocaust) and emotionally neutral.
Mental Imagery Divergent cognitive costs for online forms of reappraisal and distraction.
Emotion, 8(6), 870-874.
Boivin, J.M., Poupon-Lemarquis, L., Iraqi, W., Fay, R., Schmitt, C. & Rossignol, P.
2008 239 Children (4-12 yrs) Distraction with soap bubbles during the procedure. Games (non-electronic)
A multifactorial strategy of pain management is associated with less pain in scheduled vaccination of children. A study realized by family practitioners in 239 children aged 4-12 years old.
Family Practice, 25(6), 423-429.
Dalebroux, A., Goldstein, T.R. & Winner, E.
2008 75 Students Creating a drawing expressing their current mood (venting), creating a drawing depicting something happy (positive emotion), or scanning a sheet for specific symbols (distraction control).
Number Task Short-term mood repair through art-making: Positive emotion is more effective than venting.
Motivation and Emotion, 32(4), 288-295.
Conelea, C.A. & Woods, D.W.
2008 9 Children with Tourette syndrome (9-15 yrs)
Continuous Performance Test of Attention (CPT) and told: ‘‘At the same time, you will hear a voice on a tape say some letters. Every time you hear the voice say an ‘‘A’’ followed by an ‘‘L,’’ say ‘‘there’’ out loud.
Word Task Examining the impact of distraction on tic suppression in children and adolescents with Tourette syndrome.
Behaviour Research and Therapy, 46(11), 1193-1200.
Bartgis, J., Thomas, D.G. Lefler, E.K. & Hartung, C.M.
2008 47 Children (5 & 7 yrs)
Watching segments from the movie A Bug’s Life Film The development of attention and response inhibition in early childhood.
Infant and Child Development, 17(5), 491-502.
Philippot, P. & Brutoux, F.
2008 89 Female Students (Dysphoric & Controls)
Given written list of 10 items & asked to centre attention on each at a time imagining them vividly - think about a series of highly imaginable neutral items (e.g., ‘‘clouds forming in the sky’’ or ‘‘a boat slowly crossing the Atlantic’’). This lasted 12 mins.
Mental Imagery Induced rumination dampens executive processes in dysphoric young adults.
Journal of Behavior Therapy and Experimental Psychiatry, 39(3), 219-227.
Straube, T., Pohlack, S., Mentzel, H.J. & Miltner, W.H.R.
2008 14 Students Matching task where a small line was shown with either vertical, horizontal, or diagonal orientation equally distributed across picture categories & subjects had to identify the line orientation by pressing different buttons.
Visual Task Differential amygdala activation to negative and positive emotional pictures during an indirect task.
Behavioural Brain Research, 191(2), 285-288.
Mitchell, L.A. MacDonald, R.A.R. & Knussen, C.
2008 80 Adults (some students)
P's listened to own preferred music or viewed a choice of 1 of 15 well-known paintings.
Music An investigation of the effects of music and art on pain perception.
Psychology of Aesthetics, Creativity, and the Arts, 2(3), 162-170.
Newell, B.R. Wong, K.Y., Cheung, J.C.H. & Rakow, T.
2008 71 Students Solving simple 4–6-letter anagrams for 4-minutes. Word Task Think, blink or sleep on it? The impact of modes of thought on complex decision making
The Quarterly Journal of Experimental Psychology, 62(4), 707-732.
Kross, E. & Ayduk, 2008 469 University P's presented with a series of 45 statements (e.g., “pencils are made Mental Imagery Facilitating adaptive emotional Personality and Social Psychology
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O. Affiliates with graphite”; “Scotland is north of England”) & were asked to think about the information conveyed in each sentence when it appeared on screen.
analysis: Distinguishing distanced-analysis of depressive experiences from immersed-analysis and distraction.
Bulletin, 34(7), 924-938.
Morrison, Rebecca, O'Connor, R.C.
2008 81 Adults P's asked to visualize, focus and concentrate on a series of 45 items in an 8-minute self-paced task. Distraction: Items were focused externally away from the self and unconnected to feelings or symptoms (e.g. ‘Think about: raindrops sliding down a window pane’).
Mental Imagery The role of rumination, attentional biases and stress in psychological distress
British Journal of Psychology, 99(2), 191-209.
Hoffman, H.G. Patterson, D.R., Seibel, E., Jewett-Leahy, L., Sharar, S.R. & Soltani, M.
2008 11 Burn patients (9-40yrs)
Three minutes of water-friendly, immersive virtual reality (VR). Virtual Reality Virtual reality pain control during burn wound debridement in the hydrotank
Clinical Journal of Pain, 24(4), 299-304.
Fish, S.C. & Granholm, E.
2008 70 Schizophrenics & Healthy Adults
Digit span distractibility task. Number Task Easier tasks can have higher processing loads: Task difficulty and cognitive resource limitations in schizophrenia.
Journal of Abnormal Psychology, 117(2), 355-363.
Harmat, L., Takács, J. & Bódizs, R.
2008 94 Students Listening for 45 minutes to relaxing classical music (collection of relaxing classical music including some popular pieces from Baroque to Romantic (The Most Relaxing Classical, 2 CD, Edited by Virgin 1999) or an audiobook (11 hours of short stories by Hungarian writers such as Frigyes Karinthy, Gyula Kru´dy, Ge´za Ga´rdonyi, Zsigmond Mo´ricz and Miha´ly Babits).
Music Music improves sleep quality in students.
Journal of Advanced Nursing, 62(3), 327-335.
Pulvermüller, F., Shtyrov, Y., Hasting, A.S. & Carlyon, R.P.
2008 ? ? Passive Distraction: Watching a silent video film; Active Distraction: Attention was actively streamed away by performing a demanding acoustic signal detection task.
Film Syntax as a reflex: Neurophysiological evidence for early automaticity of grammatical processing.
Brain and Language, 104(3), 244-253.
de Tommaso, M., Baumgartner, U., Sardaro, M., Serpino, C., Treede, R-D. & Difruscolo, O.
2008 16 Migraine sufferers & healthy controls
Mental arithmetic task. Number Task Effects of distraction versus spatial discrimination on laser-evoked potentials in migraine.
Headache: The Journal of Head and Face Pain, 48(3), 408-416.
Wong, A.C.M. & Moulds, M.L.
2008 80 Students: High & low dysphoric
Eight minutes focusing on and thinking about a series of statements that focused on external stimuli.
Mental Imagery Depressive rumination and directed forgetting: An examination of encoding style
Cognitive Therapy and Research, 32(1), 1-10.
Van Damme, S., Crombez, G., Van Nieuwenborgh-De Wever, K. & Goubert, L.
2008 101 Students Random Interval Repetition (RIR) task (Vandierendonck et al., 1998).
Auditory Task Is distraction less effective when pain is threatening? An experimental investigation with the cold pressor task
European Journal of Pain, 12(1), 60-67.
Oliver, N.S. & Page, A.C.
2008 50 blood-injury-injection fearful participants (Adults)
Internal Distraction: cognitively diverting conversation to divert attention away from threatening aspects of feared stimuli and onto nonthreatening or neutral aspects of the internal environment (self), e.g. ‘‘tell me how your feet feel in your shoes right now?’’. External Distraction: same as above but topics of the external environment where a series of prompts were used to instigate
Talking Effects of internal and external distraction and focus during exposure to blood-injury-injection stimuli.
Journal of Anxiety Disorders, 22(2), 283-291.
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conversation. e.g. ‘‘what are your plans for the future?’’, and ‘‘what sort of leisure activities do you enjoy?’’
Bessell, A. L., Watkins, E. R. & Williams, W.H.
2008 58 Acquired brain injuries (ABI): 28 mild & 30 moderate/severe cognitive impairments
P's asked to focus upon a series of 28 non–self-related items e.g. “think about and imagine a boat slowly crossing the Atlantic,” “think about the layout of a typical classroom,” “think about the shape of a black umbrella.” P's asked to read each example and contemplate the meaning of the sentence.
Mental Imagery Depressive rumination reduces specificity of autobiographical memory recall in acquired brain injury.
Journal of the International Neuropsychological Society, 14(1), 63-70.
Luciano, J.V. & González, S.A.
2007 120 Students Thought suppression, thought suppression with focused distraction, thought suppression confronting a reminder, and monitor-only.
Thought Suppression
Analysis of the efficacy of different thought suppression strategies
International Journal of Psychology & Psychological Therapy, 7(3), 335-345.
Mitchell, L.A., MacDonald, R.A.R. Knussen, C. & Serpell, M.G.
2007 318 Chronic pain sufferers
Music listening. Music A survey investigation of the effects of music listening on chronic pain
Psychology of Music, 35(1), 37-57.
Schneider, S.M. & Hood, L.E.
2007 123 Cancer Patients (Adult)
Virtual reality. Virtual Reality Virtual reality: A distraction intervention for chemotherapy
Oncology Nursing Forum, 34(1), 39-46.
Vangronsveld, K.L.H., van den Hout, J.H.C. & Vlaeyen, J.W.S.
2007 20 Children (8-11 yrs) Find-the-hidden-items puzzle. Games (non-electronic)
The influence of distraction on pain and anxiety during venipuncture in children aged between 8 & 11 years
Netherlands Journal of Psychology, 63(1), 21-28.
Dahlquist, L.M., Jones, K.K., Weiss, K.E., Ackerman, C.S.& Dillinger, L.
2007 40 Children (5-13 yrs) Active and passive distraction via virtual reality. Virtual Reality Active and passive distraction using a head-mounted display helmet: Effects on cold pressor pain in children
Health Psychology, 26(6), 794-801.
Lin, Y.J. & Wicker, F.W.
2007 104 Students Thought suppression, focused-distraction, and concentration. Thought Suppression
A comparison of the effects of thought suppression, distraction and concentration.
Behaviour Research and Therapy, 45(12), 2924-2937.
Jaaniste, T., Hayes, B. & von Baeyer, C.L.
2007 78 Children (7-12 yrs) Imagery-based distraction intervention. Mental Imagery Effects of preparatory information and distraction on children's cold-pressor pain outcomes: A randomized controlled trial.
Behaviour Research and Therapy, 45(11), 2789-2799.
Moulds, M.L., Kandris, E. & Williams, A.D.
2007 93 Students Standard rumination/distraction inductions (Nolen-Hoeksema & Morrow, 1993): P's instructed to focus on and think about a series of statements for 8 minutes. Rumination induction comprises statements that are self and symptom focused, while the distraction induction contains statements that focus on external stimuli.
Mental Imagery The impact of rumination on memory for self-referent material.
Memory, 15(8), 814-821.
Lewandowski, G.W. Jr., Aron, A. & Gee, J.
2007 78 Students P’s engaged in a complex maths task: Firstly counting down from a large number (e.g., 9,748) by 7s, and after 2 min the computer instructed p's to use the number they were at and count forward by 13s for an additional 2 min.
Number Task Personality goes a long way: The malleability of opposite-sex physical attractiveness
Personal Relationships, 14(4), 571-585.
Schmid-Leuz, B., Elsesser, K., Lohrmann, T., Jöhren, P. & Sartory, G.
2007 63 Dental phobics Playing puzzle games with therapist. The therapist discussed the various moves and strategies for the completion of the puzzle.
Games (non-electronic)
Attention focusing versus distraction during exposure in dental phobia
Behaviour Research and Therapy, 45(11), 2691-2703.
Van Dillen, L.F. & 2007 117 Simple and complex maths equations e.g. 7 + 2 = 9 (simple); 2 x 8 Number Task Clearing the mind: A working Emotion, 7(4), 715 - 723.
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Koole, S.L. + 12 = 28 (complex) memory model of distraction from negative mood
Sheppes, G. & Meiran, N.
2007 30 Students P's shown 4:10-min sad film clip (holocaust survivors). Distraction: subtitles read: “Try your best to think about something that is emotionally neutral, for example: a flock of birds migrating in autumn”.
Film Better late than never? On the dynamics of online regulation of sadness using distraction and cognitive reappraisal.
Personality and Social Psychology Bulletin, 33(11), 1518 - 1532.
Forman, E.M., Hoffman, K.L., McGrath, K.B., Brandsma, L.L., Lowe, M.R. & Herbert, J.D.
2007 98 Students Memory delving, positive imagery, counting challenges, behavioral redirection (changing or leaving the current situation or environmental context). Be prepared for ‘‘automatic thoughts’’ suggesting permission to eat the chocolates, and to cognitively ‘‘confront’’ and logically restructure such thoughts. The mnemonic Distract yourself, Imagery, Scene change, Challenge/confront thoughts (DISC) was taught to aid retention (all from LEARN manual; Brownell, 2000).
Mental Imagery / Number Tasks
A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study.
Behaviour Research and Therapy, 45(10), 2372 - 2386.
Mühlberger, A., Wieser, M.J., Kenntner-Mabiala, R., Wiederhold, B.K. & Pauli, P.
2007 48 Students P's completed three 4-minute assessment periods: virtual "walks" through (1) a winter and (2) an autumn landscape and static exposure to (3) a neutral landscape.
Virtual Reality Pain modulation during drives through cold and hot virtual environments
CyberPsychology & Behavior, 10(4), 516-522.
Jeffs, D.A. 2007 32 Adolescents from allergists office (11-17 yrs)
(1) Listened to a selection from an investigator-developed collection of music, incl. alternative, hip-hop, pop, pop country & rock music. Popular teen books-on cassette and videotapes, incl. movies, music videos, sports programs, and cartoons. (2)Watched a nursing recruitment videotape targeting an adolescent audience that showed interviews with nurses, identified various nursing roles, and explained the work performed by nurses.
Music A pilot study of distraction for adolescents during allergy testing
Journal for Specialists in Pediatric Nursing, 12(3), 170-185.
Giancola, P.R. & Corman, M.D.
2007 168 Adults (males) P's simultaneously engaged in a computerized task that taxed working memory resources, i.e. asked to attend very carefully to a 3x3 matrix of 2-cm x 2-cm light-gray squares on a white computer screen. During each block, 4 squares were illuminated (in black) in a random sequential order, and p's were told that they had to remember the sequence.
Memory Task Alcohol and aggression: A test of the attention-allocation model.
Psychological Science, 18(7), 649-655.
Garcia-Palacios, A., Hoffman, H.G. Richards, T.R., Sharar, S.R. & Seibel, E.J.
2007 2 Claustrophobic patients
P's immersed in an illusory three-dimensional (3D) virtual world named SnowWorld.
Virtual Reality Use of virtual reality distraction to reduce claustrophobia symptoms during a mock magnetic resonance imaging brain scan: A case report.
CyberPsychology & Behavior, 10(3), Special issue: Impact of tasks and users' characteristics on virtual reality performance. 485-488.
Quartana, P.J., Burns, J.W. & Lofland, K.R.
2007 68 Chronic back pain sufferers
P's told ‘‘while your foot and hand are in the ice water, it is very important that you think about your bedroom at home. Picture it as clearly as you can: the arrangement of furniture, your possessions, pictures on the wall, colours and so forth. Please tell me what you’re supposed to do. Okay, concentrate only on your bedroom”.
Mental Imagery Attentional strategy moderates effects of pain catastrophizing on symptom-specific physiological responses in chronic low back pain patients.
Journal of Behavioral Medicine, 30(3), 221-231.
Versland, A. & Rosenberg, H.
2007 54 Students (Smokers) Serial sevens task. Number Task Effect of brief imagery interventions on craving in college student smokers
Addiction Research & Theory, 15(2), 177-187.
Guastella, A.J. & Moulds, M.L.
2007 114 Students Standard distraction induction used in the rumination literature was employed, e.g. ‘think about clouds forming in the sky’, ‘think about the layout of the local shopping centre’. P's were instructed
Mental Imagery The impact of rumination on sleep quality following a stressful life event.
Personality and Individual Differences, 42(6), 1151-1162.
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to focus on the induction for 8 min.Singer, A.R. & Dobson, K.S.
2007 80 Remitted depressed participants
Focus attention on mental images unrelated to mood or self, use ability to visualize and concentrate, e.g. “walk the entire length of a shopping mall, visualize the stores that you will pass on this walk,’’ ‘‘think about the way the Calgary Tower [a local landmark] looks at sunset’’, ‘‘think about all the parts that make up an automobile’’ and ‘‘think about all the steps involved in getting from your home to where you are today’’.
Mental Imagery An experimental investigation of the cognitive vulnerability to depression
Behaviour Research and Therapy, 45(3), 563-575.
Le Pera, D., Brancucci, A. De Armas, L., Miliucci, R., Restuccia, D., Valeriani, M., Rossini, P. M., Babiloni, C., Del Percio, C.
2007 10 Adults Mental arithmetic task after that stimulus, counting backwards from 1000 in steps of 7).
Number Task Inhibitory effect of voluntary movement preparation on cutaneous heat pain and laser-evoked potentials.
European Journal of Neuroscience, 25(6), 1900-1907.
Martin, P.Y., Hamilton, V.E., McKimmie, B.M., Martin, R. & Terry, D.J.
2007 148 Students (Female) Students (Male)
Low Distracter: P's told ‘please listen through your headphones to the tape recording, and count the number of times you hear a sound by pressing on the thumb counter’. High Distracter: P's required to press a thumb counter only when they heard a high pitched sound & to ignore two lower pitched sounds.
Number Task Effects of caffeine on persuasion and attitude change: The role of secondary tasks in manipulating systematic message processing.
European Journal of Social Psychology, 37(2), 320-338.
Ring, C., France, C.R., al'Absi, M., Beesley, L., Edwards, L., McIntyre, D.M., Carroll, D. & Martin, U.
2007 24 Adults P's listened to audio taped presentation of a series of single-digit integers (numbers ranging from 1 to 9) delivered at 3–4 second intervals & asked to repeat each number out loud, and to privately keep count of the occurrence of one number (e.g., 9’s).
Number Task Effects of opioid blockade with naltrexone and distraction on cold and ischemic pain in hypertension
Journal of Behavioral Medicine, 30(1), 59-68.
Cui, L. & Huang, M. 2007 64 ? Standard distraction & rumination induction (Nolen-Hoeksema, 1987).
Mental Imagery Effects of rumination and distraction on negative emotion and autobiographical memory.
Acta Psychologica Sinica, 39(1), 78-87.
Forys, K.L. & Dahlquist, L.M.
2007 95 Students P's were asked to count aloud, beginning at 1,000 and subtracting by 7s.
Number Task The influence of preferred coping style and cognitive strategy on laboratory-induced pain
Health Psychology, 26(1), 22-29.
Amorim, P.R.S., Byrne, N.M. & Hills, A.P.
2007 14 Children (8-12 yrs) TV watching for 20 mins. Film Combined effect of body position, apparatus and distraction on children's resting metabolic rate.
International Journal of Pediatric Obesity, 2(4), 249-256.
Windich-Biermeier, A., Sjoberg, I., Dale, J.C., Eshelman, D. & Guzzetta, C.E.
2007 50 Children & adolescents with cancer (5-18 yrs)
Choice of: Bubbles; I Spy: Super Challenger book; music table; virtual reality glasses; handheld video games.
Games (non-electronic) / Music /
Virtual Reality / Games (electronic)
Effects of Distraction on Pain, Fear, and Distress During Venous Port Access and Venipuncture in Children and Adolescents With Cancer.
Journal of Pediatric Oncology Nursing, 24(1), 8-19.
Lautenbacher, S., Prager, M. & Rollman, G.B.
2007 40 Adults Visual/cognitive distraction (counting numerous light signals). Number Task Pain additivity, diffuse noxious inhibitory controls, and attention: A functional measurement analysis.
Somatosensory & Motor Research, 24(4), 189-201.
Chan, E.A., Chung, J.W.Y., Wong, T.K.S., Yang, J.Y. & Lien, A.S.Y.
2007 8 Children (Burn injured)
Virtual reality game: Ice cream factory setting where children had to scare away a fox by throwing VR ice-cream at it whilst avoiding a little girl in the scene.
Virtual Reality Application of a virtual reality prototype for pain relief of pediatric burn in Taiwan
Journal of Clinical Nursing, 16(4), 786-793.
257
Mitchell, L.A.,MacDonald, R.A. R. & Brodie, E.E.
2006 44 Adults Mental arithmetic (PASAT), cognitive distraction (three types of audiotaped standup comedy), preferred music.
Number Task A comparison of the effects of preferred music, arithmetic and humour on cold pressor pain
European Journal of Pain, 10(4), 343-351.
Noguchi, L.K. 2006 64 Children (4-6.5 yrs) Musical story, spoken story, or standard care/control. Story listening The Effect of Music Versus Nonmusic on Behavioral Signs of Distress and Self-Report of Pain in Pediatric Injection Patients
Journal of Music Therapy, 43(1), 16-38.
Roelofs, J., Peters, M.L., Patijn, J., Schouten, E.G.W. & Vlaeyen, J.W.S.
2006 38 Adults (chronic non-specific low back pain patients)
Palmtop message: "pay close attention to positive things in your environment". Given camera & told to take pictures of positive things in their environment & complete a ‘photo booklet’ 3 x per day (random times) & asked to write down objects or persons which they made pictures. Also to indicate why picture was positive for them & to scan six pictures and indicate what picture they liked most and why they liked that picture most.
Visual Task An electronic diary assessment of the effects of distraction and attentional focusing on pain intensity in chronic low back pain patients.
British Journal of Health Psychology, 11(4), 595-606.
Patterson, D.R., Hoffman, H.G., Palacios, A. G. & Jensen, M.J.
2006 103 Students Virtual reality distraction (VRD) - P's followed predetermined path, “gliding” through an icy 3-D virtual canyon (Snow-World). P's aimed with their gaze direction & pushed button to shoot virtual snowballs at virtual snowmen, igloos, robots & penguins. P's saw sky when looking up, a canyon wall when looking left & river when looking down); sound effects (splash when a snowball hit the river); animated green, blue, or white colored explosions.
Virtual Reality Analgesic effects of posthypnotic suggestions and virtual reality distraction on thermal pain.
Journal of Abnormal Psychology, 115(4), 834-841.
Cohen, L.L., MacLaren, J.E., Fortson, B.L., Friedman, A., DeMore, M., Lim, C.S., Shelton, E. & Gangaram, B.
2006 136 Children (1-21 mths)
DVD movie (Sesame Street or Teletubbies) based on the choice of the parents.
Film Randomized clinical trial of distraction for infant immunization pain.
Pain, 125(1-2), 165-171.
Hoffman, H.G., Seibel, E.J., Richards, T.L., Furness, T.A. III, Patterson, D.R. & Sharar, S.R.
2006 77 Students SnowWorld (see Patterson, D.R., Hoffman, H.G., Palacios, A. G. & Jensen, M.J., 2006).
Virtual Reality Virtual Reality Helmet Display Quality Influences the Magnitude of Virtual Reality Analgesia.
The Journal of Pain, 7(11), 843-850.
Daniel, J.Z.,Cropley, M. & Fife-Schaw, C.
2006 40 Adults (Smokers) Cognitive distraction task: paced visual serial addition task (PVSAT).
Number Task The effect of exercise in reducing desire to smoke and cigarette withdrawal symptoms is not caused by distraction.
Addiction, 101(8), 1187-1192.
Piira, T., Hayes, B., Goodenough, B. & von Baeyer, C.L.
2006 120 Children (7-14 yrs) Two distraction based images described on audiotape, aimed to focus child’s attention away from physical sensations of cold-pressor task e.g. (playing ball in a favorite park, walking home with other children).
Mental Imagery Effects of attentional direction, age, and coping style on cold-pressor pain in children.
Behaviour Research and Therapy, 44(6), 835-848.
Kao, C-M., Dritschel, B.H. & Astell, A.
2006 60 Students (Dysphoric & Controls)
Focus attention on externally focused thoughts and not related to symptoms, emotions, & self, e.g. think about ‘clouds forming in the sky’, ‘the expression on the face of the Mona Lisa'.
Mental Imagery The effects of rumination and distraction on overgeneral autobiographical memory retrieval during social problem solving.
British Journal of Clinical Psychology, 45(2), 267-272.
258
Tak, J.H. & van Bon, W.H.J.
2006 136 Children (3-12 yrs) Watching funny 6 min fragment of a video cartoon (Walt Disney’s ‘The Beauty and the Beast’) was shown. Sound could be heard through a headphone.
Film Pain- and distress-reducing interventions for venepuncture in children.
Child: Care, Health and Development, 32(3), 257-268.
Burns, J.W. 2006 205 Adults (chronic low back pain patients) & Controls
Mental arithmetic task: P's performed serial subtraction by seven starting from the number 4,265.
Number Task The role of attentional strategies in moderating links between acute pain induction and subsequent psychological stress: Evidence for symptom-specific reactivity among patients with chronic pain versus healthy nonpatients.
Emotion, 6(2), 180-192.
Gold, J.I., Kim, S.H., Kant, A.J., Joseph, M.H. & Rizzo, A.
2006 20 Children (8-12 yrs) VR Distraction: Street Luge (Fifth Dimension Technologies, 5DT) - fast-moving reality-based world in which the player races downhill lying on top of a big skateboard using Street Luge.
Virtual Reality Effectiveness of virtual reality for pediatric pain distraction during IV placement
CyberPsychology & Behavior, 9(2). Special issue: Virtual and physical toys: Open-ended features for non-formal learning. 207-212
Milling, L.S., Reardon, J.M. & Carosella, G.M.
2006 188 Students Word shadowing: P's shadow monosyllabic words. One-syllable words presented at the rate of 74 words/min and p's had approx half a second to repeat back each word. P's shadowed 148 words for 2 min.
Word Task Mediation and moderation of psychological pain treatments: Response expectancies and hypnotic suggestibility.
Journal of Consulting and Clinical Psychology, 74(2), 253-262.
Hasanpour, M., Tootoonchi, M., Aein, F. & Yadegarfar, G.
2006 90 Children (5-12 yrs) Two choices depending on age and preference of child; a parallel mirror box with a small doll in the center asking them to count the mirror dolls once directly and once inversely, or asked to sing songs or do deep breathing from 3-5 min prior to the end of injection.
Number Task / Music
The effects of two non-pharmacologic pain management methods for intramuscular injection pain in children.
Acute Pain, 8(1), 7-12.
Gerin, W., Davidson, K.W., Christenfeld, N.J.S., Goyal, T. & Schwartz, J.E.
2006 60 Adults Thirty brightly colored cards and posters on screen was turned to subject. Magazines & small toys (e.g., small puzzles that required manipulating a tiny ball bearing to fall into a hole) were placed in easy reach.
Games (non-electronic)
The Role of Angry Rumination and Distraction in Blood Pressure Recovery From Emotional Arousal.
Psychosomatic Medicine, 68(1), 64-72.
Ivanec, D., Pavin, T. & Kotzmuth, A.
2006 79 Adults (Female) Classic color-based Stroop task. Visual Task Possibilities of attentional control of pain. Influence of distractive stroop task on pain threshold and pain tolerance.
Review of Psychology, 13(2), 87-94.
Nouwen, A., Cloutier, C., Kappas, A., Warbrick, T. & Sheffield, D.
2006 82 Adults (chronic back pain patient) & healthy control
P's asked to “name aloud the greatest number of forenames beginning with any letter of the alphabet that comes to mind. Once you have exhausted your repertoire of forenames, start again with the letter A.”
Word Task Effects of focusing and distraction on cold pressor-Induced pain in chronic back pain patients and control subjects.
The Journal of Pain, 7(1), 62-71.
MacLaren, J.E. & Cohen, L.L.
2005 88 Children (1-7 yrs) Interactive toy distraction, passive movie distraction, or standard care.
Games (non-electronic) / Film
A Comparison of Distraction Strategies for Venipuncture Distress in Children
Journal of Pediatric Psychology, 30(5), 387-396.
Tse, M.M.Y., Chan, M. F. & Benzie, I. F. F.
2005 57 Post-op pain (15-69 yrs)
Music therapy. Music The Effect of Music Therapy on Postoperative Pain, Heart Rate, Systolic Blood Pressure and Analgesic Use Following Nasal Surgery
Journal of Pain & Palliative Care Pharmacotherapy, 19(3), 21-29.
Kemps, E., Tiggemann, M. & Hart, G.
2005 48 Cravers & non-chocolate cravers
Imagery task: 21 coloured pictures taken from food magazines - portrayed images of 7 chocolate-containing food categories; then 1) Dynamic visual noise: p's watched a 17x17-cm matrix, comprising 80 black or white squares in each row and column.
Story listening Chocolate cravings are susceptible to visuo-spatial interference
Eating Behaviors, 6(2), 101 - 107.
259
Random squares changed from black to white or white to black at a rate of 640 changes every second; or 2) Irrelevant speech condition: p's heard a recording of a female voice reading a passage from a Dutch newspaper (None of the p's understood Dutch).
Reynolds, M., Valmana, A., Kouimtsidis, C., Donaldson, C. & Ghodse, H.
2005 60 Drug dependent patients undergoing detoxification
Relaxation group: ‘‘For the next five minutes, I would like you to record the occurrences of any thoughts you have about drugs. Try as hard as you can to suppress these thoughts, at the same time, I would like you to carry out the breathing exercises I have just taught you, but be sure to record the thoughts on the counter if they occur’’.
Thought Suppression
An investigation of descriptive and experimental aspects of intrusive thoughts in a sample of substance-dependent inpatients
Addiction Research and Theory, 13(4), 347-357.
Broderick, P.C. 2005 177 Students Cards consisting of typed phrases (45 distraction) presented in a spiral-bound booklet & instructed to read each sentence silently to themselves and use their “imagination and concentration to focus on each of the ideas.” Were asked to think about things that were not related to the self such as “a freshly painted door”.
Mental Imagery Mindfulness and Coping with Dysphoric Mood: Contrasts with Rumination and Distraction.
Cognitive Therapy and Research, 29(5), 501-510.
Dahlquist, L.M. & Pendley, J.S.
2005 29 Children (29-62 mths)
Texas Instruments Touch and Discover (Dallas, TX) portable electronic toy with interchangeable picture panels depicting animals, shapes, household items, etc. Voice of Mickey Mouse instructed children to find various pictures. When child touched a picture, the toy emitted a sound (e.g., animal or mechanical noise) & Mickey indicated if response was correct or prompted the child to try again.
Games (electronic) When Distraction Fails: Parental Anxiety and Children's Responses to Distraction during Cancer Procedures.
Journal of Pediatric Psychology, 30(7), 623-628.
Blackhart, G.C. & Kline, J.P.
2005 91 Students Forty-five items presented for approx 15s on computer screen. P's told over headphones: ‘‘for the next few minutes, try your best to focus your attention on each of the ideas presented to you on the computer screen. Item e.g. ‘‘think about the layout of a typical classroom’’ and ‘‘think about the Presidents faces on Mount Rushmore’’.
Mental Imagery Individual differences in anterior EEG asymmetry between high and low defensive individuals during a rumination/distraction task
Personality and Individual Differences, 39(2), 427-437.
Pleszczyńska, I., Stettner, Z. & Szymura, B.
2005 ? ? Listening to either a song or a melody. Music The influence of different types of distraction on working memory functioning.
Studia Psychologiczne, 43(1), 75-83.
Isaacs, J.S. 2004 ? PTSD Patients (Adult)
Numerical distraction therapy. Number Task Numerical Distraction Therapy: Initial Assessment of a Treatment for Posttraumatic Stress Disorder
Traumatology, 10(1), 39-54.
Shiv, B. & Nowlis, S.M.
2004 ? ? High distraction condition: P's asked to memorize eight-digit number; Low distraction condition: P's asked to memorize two-digit number.
Number Task The Effect of Distractions While Tasting a Food Sample: The Interplay of Informational and Affective Components in Subsequent Choice.
Journal of Consumer Research, 31(3), 599-608.
Klosky, J.L., Tyc, V.L., Srivastava, D.K., Tong, X., Kronenberg, M., Booker, Z.J., de Armendi, A.J. & Merchant, T.E.
2004 79 Children (2-7 yrs) Interactive plush Barney character interacted with a video while reinforcing key teaching points through movement and commentary & played age-appropriate games and sung songs to and with the child or non-interactive Barney sat on the treatment table while narrating vivid stories designed to distract and calm the child.
Games (electronic) Brief report: Evaluation of an interactive intervention designed to reduce pediatric distress during radiation therapy procedures
Journal of Pediatric Psychology, 29(8), 621-626.
Lattimore, P. & 2004 119 Students (Female) Modified colour-naming Stroop (CNS) tasks. Visual Task Cognitive load, stress, and Eating Behaviors, 5(4), 315-324.
260
Maxwell, L. disinhibited eatingNeumann, S.A., Waldstein, S.R., Sellers, J.J. III, Thayer, J.F. & Sorkin, J.D.
2004 80 Students (Female) Reading a neutral article about the possibility of life in outer space (Weinberger, Schwartz, & Davidson, 1979).
Story Reading Hostility and Distraction Have Differential Influences on Cardiovascular Recovery From Anger Recall in Women.
Health Psychology, 23(6), 631-640.
Gershon, J., Zimand, E., Pickering, M., Rothbaum, B.O. & Hodges, L.
2004 ? Children & adolescents with cancer (7-19 yrs)
Virtual reality. Virtual Reality A Pilot and Feasibility Study of Virtual Reality as a Distraction for Children With Cancer.
Journal of the American Academy of Child & Adolescent Psychiatry, 43(10), 1243-1249.
Donaldson, C. & Lam, D.
2004 72 Adults (major depression patients & controls)
Attempt to focus attention externally & involved playing a board game (noughts & crosses or Scrabble).
Games (non-electronic)
Rumination, mood and social problem-solving in major depression.
Psychological Medicine, 34(7), 1309-1318.
Telch, M.J., Valentiner, D.P., Ilai, D., Young, P.R., Powers, M.B. & Smits, J.A.J.
2004 60 Students (severely claustrophobic)
P's performed a demanding cognitive load task (modified Seashore Rhythm Test).
Auditory Task Fear activation and distraction during the emotional processing of claustrophobic fear.
Journal of Behavior Therapy and Experimental Psychiatry, 35(3), 219-232.
Hoffman, H.G., Sharar, S.R., Coda, B., Everett, J.J., Ciol, M., Richards, T. & Patterson, D.R.
2004 39 Students P's followed a pre-determined path, ‘gliding’ through an icy 3-dimensional virtual canyon (SnowWorld).
Virtual Reality Manipulating presence influences the magnitude of virtual reality analgesia.
Pain, 111(1-2), 162-168.
Ohara, S., Crone, N.E., Weiss, N. & Lenz, F.A.
2004 4 Adults (epileptics) Reading a magazine article in anticipation of being asked comprehension questions.
Reading Attention to a painful cutaneous laser stimulus modulates electrocorticographic event-related desynchronization in humans
Clinical Neurophysiology, 115(7), 1641-1652.
Park, R.J., Goodyer, I.M. & Teasdale, J.D.
2004 134 Children & adolescents with current full Major Depressive Disorder or in partial remission (12–17 yrs) or controls
Based on Nolen-Hoeksema & Morrow (1993) "Think about and imagine a boat slowly crossing the Atlantic", "a kettle coming to the boil", "a band playing outside", "a double-decker bus driving down the street".
Mental Imagery Effects of induced rumination and distraction on mood and overgeneral autobiographical memory in adolescent Major Depressive Disorder and controls
Journal of Child Psychology and Psychiatry, 45(5), 996-1006.
Goubert, L., Crombez, G., Eccleston, C. & Devulder, J.
2004 52 Adults (with chronic or recurrent back pain)
Random Interval Repetition (RIR) Task (Vandierendonck et al., 1998). During 60 s, p's instructed to respond as quickly as possible to computer-generated tones by pressing a button held in the dominant hand.
Auditory Task Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain.
Pain, 110(1-2), 220-227.
Schmahl, C., Greffrath, W., Baumgärtner, U., Schlereth, T., Magerl, W., Philipsen, A., Lieb, K., Bohus, M. & Treede, R-D.
2004 24 Adults (Female; with borderline personality disorder & controls)
Mental arithmetic task - P's given large starting number (3–4 digits) and told to silently subtract a one-digit number consecutively.
Number Task Differential nociceptive deficits in patients with borderline personality disorder and self-injurious behavior: Laser-evoked potentials, spatial discrimination of noxious stimuli, and pain ratings
Pain, 110(1-2), 470-479.
Dowman, R. 2004 28 Adults Mental arithmetic task: P's counted backwards by 3 starting with a Number Task Distraction produces an increase in Psychophysiology, 41(4), 613-624.
261
pseudo-randomly chosen three-digit number. pain-evoked anterior cingulate activity.
Lavender, A. & Watkins, E.
2004 60 Adults (Clinically depressed & controls)
Focus attention on 45 items, e.g. ‘Think about the shape of a large black umbrella’, ‘Think about a ship crossing the ocean’, ‘Think about the Mona Lisa’, ‘Think about a raindrop sliding down a pane of glass’ for a total of 8 minutes.
Mental Imagery Rumination and future thinking in depression.
British Journal of Clinical Psychology, 43(2), 129-142.
Crust, L., Clough, P.J. & Robertson, C.
2004 57 Students Talking, instrumental music and lyrical music. Music Influence of Music and Distraction on Visual Search Performance of Participants With High and Low Affect Intensity
Perceptual and Motor Skills, 98(3,Pt1), 888-896.
Roelofs, J., Peters, M.L., van der Zijden, M. & Vlaeyen, J.W.S.
2004 90 Students Tone-discriminating task where high (1000 Hz) and low (250 Hz) tones presented. P's were instructed to respond whether a high or low tone was presented on a response box.
Auditory Task Does fear of pain moderate the effects of sensory focusing and distraction on cold pressor pain in pain-free individuals?
The Journal of Pain, 5(5), 250-256.
Joormann, J. & Siemer, M.
2004 119 Students Focused attention on externally focused thoughts & not symptoms, emotions, or self, e.g. "imagine walking down a shopping center", "take a look at all the shops on the way". Eight minutes of focusing on 8 items (self-paced).
Mental Imagery Memory Accessibility, Mood Regulation, and Dysphoria: Difficulties in Repairing Sad Mood With Happy Memories?
Journal of Abnormal Psychology, 113(2), 179-188.
Masuda, A., Hayes, S.C., Sackett, C.F. & Twohig, M.P.
2004 8 Students (Female) P's asked to read an article on Japan for 5 min. Reading Cognitive defusion and self-relevant negative thoughts: Examining the impact of a ninety year old technique
Behaviour Research and Therapy, 42(4), 477-485.
Johnstone, K.A. & Page, A.C.
2004 27 Students (Spider phobic)
Stimulus-irrelevant conversation. Talking Attention to phobic stimuli during exposure: The effect of distraction on anxiety reduction, self-efficacy and perceived control.
Behaviour Research and Therapy, 42(3), 249-275.
Holmes, E.A., Brewin, C.R. & Hennessy, R.G.
2004 27 Students (Male) Verbal mental arithmetic task: Count backward in threes from 958. Number Task Trauma Films, Information Processing, and Intrusive Memory Development.
Journal of Experimental Psychology: General, 133(1), 3-22.
Unrod, M., Kassel, J.D. & Robinson, M.
2004 80 Students (Smokers) View and rate a series of art slides. Visual Task Effects of Smoking, Distraction, and Gender on Pain Perception
Behavioral Medicine, 30(3), 133-139.
Filcheck, H.A., Allen, K.D., Ogren, H., Darby, J.B., Holstein, B. & Hupp, S.
2004 60 Children (5-8 yrs) Listening to music, soundtracks, and/or audio stories while undergoing dental treatment.
Music The Use of Choice-Based Distraction to Decrease the Distress of Children at the Dentist.
Child & Family Behavior Therapy, 26(4), 59-68.
Borckardt, J.J.,Younger, J., Winkel, J., Nash, M.R. & Shaw, D.
2004 120 Students Listening to a story. Story listening The Computer-Assisted Cognitive/Imagery System for use in the management of pain.
Pain Research & Management, 9(3), 157-162.
Rief, W., Sander, E., Günther, M. & Nanke, A.
2004 33 Adults (Tinnitus sufferers)
Listen to music. Music Steering selective attention in tinnitus: An experimental psychophysiological study.
Zeitschrift für Klinische Psychologie und Psychotherapie: Forschung und Praxis, 33(3), 230-236.
Gershon, J., Zimand, E., Lemos, R., Rothbaum, B.O. & Hodges, L.
2003 1 Child (8 yrs) VR Distraction: Virtual Gorilla program where user takes on persona of an adolescent gorilla in a gorilla habitat and can interact with the other gorillas with a joystick & headset. Non-VR Distraction: Same but displayed on computer monitor without head-mounted display.
Virtual Reality Use of virtual reality as a distractor for painful procedures in a patient with pediatric cancer: A case study
CyberPsychology & Behavior, 6(6), 657-661.
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Steele, E., Grimmer, K., Thomas, B., Mulley, B., Fulton, I. & Hoffman, H.
2003 1 Adolescent (16 yrs) Patient interacted with virtual world through movement of their head, which aimed a virtual gun, and through a hand-held trigger, which could be used to shoot at virtual creatures for 5 minutes of play.
Virtual Reality Virtual Reality as a Pediatric Pain Modulation Technique: A Case Study
CyberPsychology & Behavior; 6(6), 633-638.
Dromey, C. & Benson, A.
2003 20 Young Adults (?) Motor Task: Putting together washers, nuts and bolts; Linguistic Task: Generating verbs from nouns; Cognitive Task: Mental arithmetic.
Word Task / Number Task
Effects of Concurrent Motor, Linguistic, or Cognitive Tasks on Speech Motor Performance.
Journal of Speech, Language, and Hearing Research, 46(5), 1234-1246.
Hinrichsen, H. & Clark, D.M.
2003 80 Students (High & Low Social Anxiety)
Viewing a film of insects in their natural habitat & rating the likeability of each insect.
Film Anticipatory processing in social anxiety: Two pilot studies.
Journal of Behavior Therapy and Experimental Psychiatry, 34(3-4), 205-218.
Faymonville, M-E., Roediger, L., Del Fiore, G., Delgueldre, C., Phillips, C., Lamy, M., Luxen, A., Maquet, P. & Laureys, S.
2003 19 Adults Mental imagery task: P's instructed to simply imagine a pleasurable autobiographical memory.
Mental Imagery Increased cerebral functional connectivity underlying the antinociceptive effects of hypnosis
Cognitive Brain Research, 17(2), 255-262
Lyubomirsky, S., Kasri, F. & Zehm, K.
2003 210 Students (Dysphoric & Controls)
P's focus on 45 items not related to emotions, symptoms, or self, e.g. think about “a lone cactus in the desert”, “the size of the Statue of Liberty”, “a parking lot at a drive-in”.
Mental Imagery Dysphoric Rumination Impairs Concentration on Academic Tasks.
Cognitive Therapy and Research, 27(3), 309-330.
Vickers, K.S. & Vogeltanz-Holm, N.D.
2003 170 Students (Dysphoric & Controls)
P's focus on items not related to symptoms, emotions, or self, e.g. “the layout of a typical classroom”.
Mental Imagery The Effects of Rumination and Distraction Tasks on Psychophysiological Responses and Mood in Dysphoric and Nondysphoric Individuals.
Cognitive Therapy and Research, 27(3), 331-348
Schneider, S.M., Ellis, M., Coombs, W.T., Shonkwiler, E.L. & Folsom, L.C.
2003 60 Adults (Female 50+ yrs)
VR Distraction: P's chose from three CD-ROM based scenarios; (Oceans Below®, A World of Art®, or Titanic: Adventure Out of Time®).
Virtual Reality Virtual Reality Intervention for Older Women with Breast Cancer
CyberPsychology & Behavior, 6(3), 301-307.
Huang, L. 2003 101 Students Cognitive Operation: Continued deduction (counting with pen) plus an oral report of the processing.
Number Task Effect of cognitive operation on pain threshold and pain tolerance.
Chinese Mental Health Journal, 17(4), 261-262.
Waters, W.F., Hurry, M.J., Binks, P.G., Carney, C.E., Lajos, L.E., Fuller, K.H., Betz, B., Johnson, J., Anderson, T. & Tucci, J.M.
2003 53 Chronic Insomniacs Reading from book (preferably novel) at bedtime for 30 mins & using visual imagery of scenes, characters & action, mentally reviewing what was read & extrapolating plot until sleep. Permissible variations included using books on tape or recalling material from TV shows or movies.
Reading Behavioral and Hypnotic Treatments for Insomnia Subtypes.
Behavioral Sleep Medicine, 1(2), 81-101.
Lutz, R.S. 2003 104 Students P's crossed off ‘as many vowels as possible’ from a page of random letters for the same time period.
Word Task Covert muscle excitation is outflow from the central generation of motor imagery.
Behavioural Brain Research, 140(1-2), 149-163.
Oliver, N.S. & Page, A.C.
2003 48 Students (blood-injection fearful)
P's engaged in conversations that didn't involve focusing on fear stimulus (neutral topics) prompts were used to instigate conversation (e.g. ‘What are your plans for the future?’ and ‘What sort of leisure activities do you enjoy?’)
Talking Fear reduction during in vivo exposure to blood-injection stimuli: Distraction vs. attentional
British Journal of Clinical Psychology, 42(1), 13-25.
Tse, M.M.Y. 2003 72 Adults Visual stimulation through lightweight eye glasses of nature scenes of mountains, waterfalls, flowers & trees.
Mental Imagery Visual stimulation: Non-pharmacological pain relief.
Annual Review of CyberTherapy and Telemedicine, 1, 73-76.
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Milling, L.S. & Breen, A.
2003 167 Students Word shadowing: P's practiced shadowing words presented on an audiotape, 1 syllable words presented at rate of 74 words per min & P's had approx half second to repeat back each word.
Word Task Mediation and moderation of hypnotic and cognitive-behavioural pain reduction.
Contemporary Hypnosis, 20(2), 81-97
Hoffman, H.G., Garcia-Palacios, A., Kapa, V., Beecher, J. & Sharar, S.R.
2003 22 Students Ordinary VE or VE with tactile augmentation: P's were placed in middle of virtual kitchen & could “pick up” virtual objects (e.g., a spider and a candy bar) with their cyberhand.
Virtual Reality Immersive virtual reality for reducing experimental ischemic pain.
International Journal of Human-Computer Interaction, 15(3), 469-486.
de Tommaso, M., Valeriani, M., Guido, M., Libro, G., Specchio, L.M., Tonali, P. & Puca, F.
2003 55 Chronic migraine without aura & normal controls
P's asked to solve digit subtraction problems, according to Beydoun et al. (1993).
Number Task Abnormal brain processing of cutaneous pain in patients with chronic migraine.
Pain, 101(1-2), 25-32
Switkin, M.C., Gelfand, K.M., Amari, A., Dahlquist, L.M., Slifer, K. & Eskenazi, A.E.
2002 1 Child (4yrs) The "evaluative" distractor, required the child to perform pre-academic tasks, and the "non-evaluative" distractor, was an interactive book.
Reading The impact of types of distractors on child-critical statements by a caregiver during chemotherapy injections: A case study
Children's Health Care, 31(4), 311-319.
Escera, C., Corral, M-J. & Yago, E.
2002 12 Adults P's classified odd/even numbers presented on a computer screen 300 ms after the occurrence of a task-irrelevant auditory stimulus, by pressing the corresponding response button.
Number Task An electrophysiological and behavioral investigation of involuntary attention towards auditory frequency, duration and intensity changes.
Cognitive Brain Research, 14(3), 325-332.
Fauerbach, J.A.,Lawrence, J.W. & Haythornthwaite, J.A.
2002 42 Adults (hospitalized acute burn patients)
P's given choice of music (selection of 20 different types) & instructed in active listening techniques - taught how to focus attention on 4 aspects of music: varying melodies, style or emotional tone, identifying different instruments & lyrics. P's told to monitor attention & bring it back to music if it wandered & encouraged to enjoy the music (played on portable stereo).
Music Coping with the stress of a painful medical procedure
Behaviour Research and Therapy, 40(9), 1003-1015.
De Bourdeaudhuij, I., Crombez, G., Deforche, B., Vinaimont, F., Debode, P. & Bouckaert, J.
2002 30 Children & Adolescents (9-17 yrs)
P's heard their favorite piece of music by loudspeakers from the beginning of the treadmill test until the end of cooling down.
Music Effect of distraction on treadmill running time in severely obese children and adolescents.
International Journal of Obesity, 26(8), 1023-1029.
Sakai, K., Rowe, J.B. & Passingham, R.E.
2002 12 Adults Mental arithmetic task - serial addition of five numbers. Number Task Parahippocampal reactivation signal at retrieval after interruption of rehearsal.
Journal of Neuroscience, 22(15), 6315-6320.
Cassidy, K-L., Reid, G.J., McGrath, P.J., Finely, G.A., Smith, D.J., Morley, C., Szudek, E.A. & Morton, B.
2002 62 Children (5 yrs) P's asked to watch cartoon on TV screen - section of cartoon chosen was at a point in a musical number deliberately selected to be immediately and optimally engaging.
Film Watch needle, watch TV: Audiovisual distraction in preschool immunization.
Pain Medicine, 3(2), 108-118.
James, J.E. & Hardardottir, D.
2002 72 Students P's told to attend closely to computer monitor which showed ‘targets’ of 2, 4 & 6 alphabetic characters followed by a string of 20 characters. P's indicated whether the string contained all the characters.
Word Task Influence of attention focus and trait anxiety on tolerance of acute pain.
British Journal of Health Psychology, 7(2), 149-162.
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Callaghan, P. & Li, H.C.
2002 48 Adults (Females undergoing elective hysterectomies)
P's taught to direct their attention to more favourable aspects of their present situation whenever they anticipated or experienced discomfort.
Thought Suppression
The effect of pre-operative psychological interventions on post-operative outcomes in Chinese women having an elective hysterectomy.
British Journal of Health Psychology, 7(2), 247-252.
Harvey, A.G. & Payne, S.
2002 41 Students (Insomniacs)
Imagery: During pre-sleep period they should distract themselves by imagining a situation they found interesting, engaging, pleasant & relaxing. P's told to close eyes & spend 2 mins imagining the scene in as much detail as possible. Questions asked to maximise vividness & engagingness, e.g. “What could you see around you?”, “How were you feeling?”, “What could you feel around you?”, “Were you able to hear any sounds or voices?”, “What was the general atmosphere like?”
Mental Imagery The management of unwanted pre-sleep thoughts in insomnia: Distraction with imagery versus general distraction.
Behaviour Research and Therapy, 40(3), 267-277.
Cohen, L.L. 2002 90 Children (2 mth-3 yrs)
Teletubbies movie (Wood & Davenport, 1997) played on television/ VCR & infants’ attention directed to movie using animated gestures & speech (e.g., “Look at that!”). Nurse also used age appropriate toys (e.g., rattles, electronic phones, dolls) to distract child throughout the procedure.
Film Reducing infant immunization distress through distraction.
Health Psychology, 21(2), 207-211.
Bantick, S.J., Wise, R.G., Ploghaus, A., Clare, S., Smith, S.M. & Tracey, I.
2002 8 Adults Counting Stroop Task (Bush et al, 1998): P’s shown sets of between 1 & 4 identical words presented on screen as a vertical list, which changed every 1.25s. Asked to record the no of words presented on screen (regardless of the word itself) using button corresponding to the no of words presented as quickly and accurately as possible.
Word Task Imaging how attention modulates pain in humans using functional MRI.
Brain: A Journal of Neurology, 125(2), 310-319.
Dahlquist, L.M., Pendley, J., S., Landtrip, D.S. Jones, C. L. & Steuber, C. P.
2002 29 Children (2-5 yrs) Texas Instruments Touch & Discover (Dallas, TX) electronic toy - lightweight, portable toy comes with several picture panels depicting themes appropriate for preschool-age children (e.g., barnyard animals, common household objects). Voice of Mickey Mouse directs child to press a picture; each picture produces a sound when pressed. Picture panels vary in task difficulty - some require conceptual matching (e.g., “Find the yellow ball.”); others match a picture with a sound (e.g., a picture of a cow–moo).
Games (electronic) Distraction intervention for preschoolers undergoing intramuscular injections and subcutaneous port access
Health Psychology, 21(1), 94-99.
Annesi, J.J. 2001 50 Adults Music and personal television. Music / Film Effects of music, television, and a combination entertainment system on distraction, exercise adherence, and physical output in adults
Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 33(3), 193-202.
Woike, B., Lavezzary, E. & Barsky, J.
2001 58 Adults P's viewed color swatches in booklets and wrote the object that came to mind for each color and gave it a name (10 mins).
Word Task The influence of implicit motives on memory processes.
Journal of Personality and Social Psychology, 81(5), 935-945.
Antony, M.M., McCabe, R.E. Leeuw, I., Sano, N. & Swinson, R.P.
2001 60 Adults (Spider phobics)
Listening to an educational audiotape on world geography. Story listening Effect of distraction and coping style on in vivo exposure for specific phobia of spiders.
Behaviour Research and Therapy, 39(10), 1137-1150.
Hoffman, H.G., Patterson, D.R., Carrougher, G.J. & Sharar, S.R.
2001 7 Burn patients (9-32yrs)
Virtual reality. Virtual Reality Effectiveness of virtual reality-based pain control with multiple treatments.
Clinical Journal of Pain, 17(3), pp. 229-235.
265
Vadhan, N.P., Serper, M.R. Harvey, P.D. Chou, J.C.-Y. & Cancro, R.
2001 56 Adult (acute schizophrenic inpatients)
Digit span distraction test. Number Task Convergent validity and neuropsychological correlates of the Schedule for the Assessment of Negative Symptoms (SANS) attention subscale.
Journal of Nervous and Mental Disease, 189(9), 637-641.
Hoffman, H.G., Garcia-Palacios, A., Patterson, D.R. Jensen, M., Furness, T. & Ammons, W.F.
2001 2 Adult (Dental patients)
VR: SnowWorld (icy 3D virtual canyon with a river and waterfalls). P’s followed a path through world, and could “look around” using an ordinary mouse to change gaze direction. P's shot snowballs at snowmen and igloos by aiming with gaze (via the mouse) and pressing spacebar to shoot. Snowballs exploded with animations and 3D sound effects on impact. Distraction: movie “Casablanca” while wearing special personal movie viewing glasses).
Virtual Reality The effectiveness of virtual reality for dental pain control: A case study.
CyberPsychology & Behavior, 4(4), 527-535.
Bonk, V.A., France, C.R. & Taylor, B.K.
2001 112 Adults (1st time blood donors)
Watching a 3-dimensional video. Film Distraction reduces self-reported physiological reactions to blood donation in novice donors with a blunting coping style.
Psychosomatic Medicine, 63(3), 447-452.
Sparks, L. 2001 105 Children (4-6 yrs) Touch Distraction: Light stroking of the skin around the injection site was administered by investigator just prior to and during injection. Stroking was moderate in intensity and near the injection site. Bubble-blowing Distraction: during the injection as it helps child breathe more deeply and exhale slowly to promote relaxation.
Games (non-electronic)
Taking the 'ouch' out of injections for children.
MCN: The American Journal of Maternal/Child Nursing, 26(2), 72-78.
Haythornthwaite, J.A., Lawrence, J.W. & Fauerbach, J.A.
2001 42 Adult (Burn inpatients)
P’s given an extensive choice of music to listen to (they selected from 20 diff types of music) and were instructed in active listening techniques. Taught how to focus attention on 4 aspects of music: varying melodies, style or emotional tone, identifying different instruments & lyrics - instructed to monitor attention and continually bring it back to the music if it wandered. P’s encouraged to enjoy the music.
Music Brief cognitive interventions for burn pain.
Annals of Behavioral Medicine, 23(1), 42-49.
Bentsen, B., Svensson, P. & Wenzel, A.
2001 23 Adult (Dental patients)
3D video about roller-skating -chosen as had been assessed to have a neutral content since the idea was to draw the patient's attention to the scenery, not to involve the patient emotionally.
Film Evaluation of effect of 3D video glasses on perceived pain and unpleasantness induced by restorative dental treatment.
European Journal of Pain, 5(4), 373-378.
Freeman, R., Barabasz, A., Barabasz, M. & Warner, D.
2000 20 ? Memorization of a sequence of colored light. Memory Task Hypnosis and distraction differ in their effects on cold pressor pain.
American Journal of Clinical Hypnosis, 43(2), 137-148.
Carrillo, M.C., Gabrieli, J.D.E. & Disterhoft, J.F.
2000 ? Adults Concurrently watching a silent movie or concurrent verbal shadowing.
Film Selective effects of division of attention on discrimination conditioning.
Psychobiology, 28(3), 293-302.
Hadjistavropoulos, H.D., Hadjistavropoulos, T. & Quine, A.
2000 81 Adults (Chronic pain patients)
P's told to distract and avoid monitoring physical sensations (i.e. think of anything other than physical sensations during the sessions by using distraction).
Mental Imagery Health anxiety moderates the effects of distraction versus attention to pain.
Behaviour Research and Therapy, 38(5), 425-438.
Carlson, K.L., 2000 384 Children & P's given Illusion Kaleidoscope to look through & instructed in its Games (non- Using distraction to reduce reported Journal of the Society of Pediatric
266
Broome, M. & Vessey, J.A.
Adolescents (4-18 yrs)
use. Toy selected because it requires no manipulation to change images; rather, glitter suspended in a fluid-filled tube (e.g., space tube) passes before the lens when held to the eye. P's encouraged to concentrate on what they were seeing by phrases such as “Do you see the different designs?” Throughout the procedure the child was asked to describe the changes in the visual images.
electronic) pain, fear and behavioral distress in children and adolescents: A multisite study.
Nurses, 5(2), 75-85
Yamasaki, H., Kakigi, R., Watanabe, S. & Hoshiyama, M.
2000 11 Adults Twenty-five random two-digit numbers were projected on a screen. ‘‘Calculation task’’ was to add the 5 numbers on each line. ‘‘Memorization task’’ was to memorize as many as possible of the 5 numbers on each line.
Number Task Effects of distraction on pain-related somatosensory evoked magnetic fields and potentials following painful electrical stimulation.
Cognitive Brain Research, 9(2), 165-175.
Kassel, J.D. & Unrod, M.
2000 67 Adults (Smokers) P's asked to view a series of art slides and answer the same four questions per slide (e.g., "What do you think of the use of colours in this painting?").
Visual Task Smoking, anxiety, and attention: Support for the role of nicotine in attentionally mediated anxiolysis
Journal of Abnormal Psychology, 109(1), 161-166
Fanurik, D., Koh, J.L. & Schmitz, M.L.
2000 160 Children & Adolescents (2–16 yrs)
Bubbles & musical sound story books were used with the two youngest age groups. Sound story books and headsets with a choice of a selection of music were used for children in the 9-12 year group, depending on their preferences as well as staff assessment of attention span and maturity. Children 13 years and older listened to their choice of a selection of music through headsets.
Games (non-electronic) / Story
Listening
Distraction techniques combined with EMLA: Effects on IV insertion pain and distress in children.
Children's Health Care, 29(2), 87-101.
Manimala, M.R., Blount, R.L. & Cohen, L.L.
2000 82 Children (3.8–5.9 yrs)
Playing with toys, puzzles, drawing, colouring, reading books, and talking about non-medical topics (e.g., pets, friends, etc.). Parents instructed to teach & encourage children to use party blower throughout as it incorporates aspects of distraction as well as possible relaxation due to changes in breathing patterns.
Games (non-electronic)
The effects of parental reassurance versus distraction on child distress and coping during immunizations.
Children's Health Care, 29(3), 161-177.
Cohen, L.L., Blount, R.L., Cohen, R.J., Schaen, E.R. & Zaff,, J.F.
1999 39 Children (4th grade)
Nurse assisted children in selecting movie to watch during procedure & trained to use comments (e.g., "Which one is the good guy?" and "Tell me what is happening in the movie"), direct commands (e.g., "Watch the movie!"), and gestures to encourage children to attend to movie throughout. 4th grade children nominated (prior to study) the movies Casper, Space Jam, Toy Story, Mighty Morphin Power Rangers, 101 Dalmatians, and Free Willy 3.
Film Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations.
Health Psychology, 18(6), 591-598.
Lyubomirsky, S., Tucker, K.L., Caldwell, N.D. & Berg, K.
1999 90 Students P's focused attention on thoughts that were focused externally and not related to symptoms, emotions, or self, e.g. they were asked to think about "a boat slowly crossing the Atlantic," "the expression on the face of the Mona Lisa and a truckload of watermelons."
Mental Imagery Why ruminators are poor problem solvers: Clues from the phenomenology of dysphoric rumination.
Journal of Personality and Social Psychology, 77(5), 1041-1060.
Hull, G.R. & Potteiger, J.A.
1999 10 Adult (Females) Viewing a high-action or low-action video. Film Regulation of exercise intensity using ratings of perceived exertion during passive visual distraction.
Perceptual and Motor Skills, 89(2), 684-694.
Mason, S., Johnson, M.H. & Woolley, C.
1999 8 Children (2.4–4.5 yrs) with either acute lymphocytic leukemia, non-Hodgkin's lymphoma, or
Brief film (video cartoon) or a short story. Film A comparison of distractors for controlling distress in young children during medical procedures.
Journal of Clinical Psychology in Medical Settings, 6(3), 239-248.
267
Wilms' tumorYzerbyt, V.Y., Coull, A. & Rocher, S.J.
1999 234 Students P's played a simple computerized visual-tracking game whilst listening to the tape: A letter X moved erratically along a horizontal line ranging from the left end to the right end of the screen. P's had no control over the movements of this letter. Beneath the letter, a string of five letters, forming a short line, was also moving horizontally on the screen. By pressing the space bar on the computer keyboard, participants could reverse the direction of this line. Their goal was to guide the line in such a way that the letter X would always be localized between the two extremities of the line. Whenever either the letter X or the line reached the end of the screen, it would simply reverse direction automatically.
Games (electronic) Fencing off the deviant: The role of cognitive resources in the maintenance of stereotypes.
Journal of Personality and Social Psychology, 77(3), 449-462.
Trask, P.C. & Sigmon, S.T.
1999 119 Adults P's asked to focus their attention on a series of ideas and thoughts & use their ability to visualize and concentrate. Asked to "walk the entire length of the shopping mall, visualizing the stores that you will pass on this walk", "think about the shape of the State", "describe to yourself what a moose looks like".
Mental Imagery Ruminating and distracting: The effects of sequential tasks on depressed mood.
Cognitive Therapy and Research, 23(3), 231-246.
Schneider, S.M. & Workman, M.L.
1999 11 Children & Adolescents (10-17 yrs)
VR games delivered through a headset. Virtual Reality Effects of virtual reality on symptom distress in children receiving chemotherapy.
CyberPsychology & Behavior, 2(2), 125-134.
Hanley, J.R., Baker, G.A. & Ledson, S.
1999 60 Adults (with amnesia, normal control, normal individuals who had been asked to simulate amnesia)
P's presented with 30 white 6 x 4 inch cards one at a time - each contained 3 different nouns in uppercase arranged in a horizontal line & all related to different semantic category & not normatively associated with each other. P's required to read aloud the 3 words on the stimulus card, and were tested 20 s later. Also p's required to count backwards by ones from a random three-digit number during the 20-s delay.
Word Task / Number Task
Detecting the faking of amnesia: A comparison of the effectiveness of three different techniques for distinguishing simulators from patients with amnesia.
Journal of Clinical and Experimental Neuropsychology, 21(1), 59-69.
Nairne, J.S., Whiteman, H.L. & Kelley, M.R.
1999 128 Students Following final item of each list, p's engaged in a digit-tracking distractor task for 2, 8, 16, or 32 sec. Task involved reading aloud digits (0±9) that appeared individually at the center of the computer screen at a rate of 500 msec per digit - distraction interval was immediately followed by the order reconstruction task.
Number Task Short-term forgetting of order under conditions of reduced interference.
The Quarterly Journal of Experimental Psychology A: Human Experimental Psychology, 52A(1), 241-251.
Penfold, K. & Page, A.C.
1999 39 Students (mildly blood- and injection-fearful)
Stimulus-irrelevant conversation. Talking The Effect of Distraction on Within-Session Anxiety Reduction During Brief In Vivo Exposure for Mild Blood-Injection Fears.
Behavior Therapy, 30(4), 607-621.
Furnham, A. & Allass, K.
1999 48 Students Simple & complex music listening - Low' by REM; 'You have been loved' by George Michael; 'Only the wind' by Pet Shop Boys (total length of 'simple' music, 13 min 18 s; mean tempo, 64 bpm). 'Scream' by Michael Jackson; 'Runnin' for the red light' by Meatloaf; 'Poison' by Alice Cooper (total length of 'complex' music, 12 min 5 s; mean tempo, 118 bpm).
Music The influence of musical distraction of varying complexity on the cognitive performance of extroverts and introverts.
European Journal of Personality, 13(1), 27-38.
Cann, A., Holt, K. & Calhoun, L.G
1999 96 Students Viewing a humorous videotape or a non-humorous videotape. Film / Humour The roles of humor and sense of humor in responses to stressors.
Humor: International Journal of Humor Research, 12(2), 177-193.
Clark, R.E. & Squire, L.R.
1999 38 Adults TV monitor presented a sequence of single digits (one every 1.5s for a 1s duration) throughout conditioning session & P's asked to
Number Task Human eyeblink classical conditioning: Effects of manipulating
Psychological Science, 10(1), 14-18.
268
press a button when they saw three odd digits consecutively. awareness of the stimulus contingencies.
Johnson, M.H., Breakwell, G., Douglas, W. & Humphries, S.
1998 50 Adults Thermal and light detection, and neutral imagining & imagining an enjoyable holiday.
Mental Imagery The effects of imagery and sensory detection distractors on different measures of pain: How does distraction work?
British Journal of Clinical Psychology, 37(2), 141-154.
Johnson, S.K., DeLuca, J., Diamond, B.J. & Natelson, B.H.
1998 71 Adults (25 with CFS; 15 with MS, 14 with depression & 17 controls)
Mental arithmetic: Counting backwards by 3s from 100 (5sec) or counting backwards by 3s from 50 (15sec); Letter task: Reading aloud visually presented letters.
Number Task Memory dysfunction in fatiguing illness: Examining interference and distraction in short-term memory.
Cognitive Neuropsychiatry, 3(4), 269-285.
Monteith, M.J. & Voils, C.I.
1998 125 Students Between jokes, 18 pictures of objects (e.g., rose, cactus, and building) would appear on the monitor. Low-cognitive-load p's told to find the object that appeared 4 times and remember that object. High-cognitive load p's asked to count number of pairs of objects on the screen (between 3 & 7 pairs were presented), find object that appeared 4 times & remember both that object & total number of pairs.
Visual Task Proneness to prejudiced responses: Toward understanding the authenticity of self-reported discrepancies
Journal of Personality and Social Psychology, 75(4), 901-916.
Lyubomirsky, S., Caldwell, N.D. & Nolen-Hoeksema, S.
1998 233 Students (Dysphorics & controls)
P's focused their attention on thoughts that were focused externally and not related to symptoms, emotions, or self, e.g. they were asked to think about "clouds forming in the sky," "the expression on the face of the Mona Lisa,'' and ' 'the shiny surface of a trumpet''.
Mental Imagery Effects of ruminative and distracting responses to depressed mood on retrieval of autobiographical memories.
Journal of Personality and Social Psychology, 75(1), 166-177.
Rusting, C.L. & Nolen-Hoeksema, S.
1998 256 Students P's asked to focus their attention on external non-emotional content, e.g. they were asked to think about items such as "the layout of the local post office'' and ' 'a double-decker bus driving down the street”.
Mental Imagery Regulating responses to anger: Effects of rumination and distraction on angry mood.
Journal of Personality and Social Psychology, 74(3), 790-803.
Lautenbacher, S., Pauli, P., Zaudig, M. & Birbaumer, N.
1998 28 Adults (inpatients with psychosomatic disorders)
Mental arithmetic task : (Pauli Test) consisting of columns of one digit numbers where P’s are asked to repeatedly add two consecutive numbers and to enter results.
Number Task Attentional control of pain perception: The role of hypochondriasis.
Journal of Psychosomatic Research, 44(2), 251-259.
Wallace, D.S., West, S., Wandell, C., Ware, A. & Dansereau, D.F.
1998 41 Students The 45-word Delta Reading Vocabulary Test (Deignan, 1973). Word Task The effect of knowledge maps that incorporate gestalt principles on learning.
Journal of Experimental Education, 67(1), 5-16.
van Zuuren, F.J. 1998 61 Females (16-40 yrs) hospitalized with preterm labor
Fifteen minute cheerful cartoon about conception and childbirth in general, but unrelated to preterm labor.
Film The effects of information, distraction and coping style on symptom reporting during preterm labor
Psychology & Health, 13(1), 49-54.
Farthing, G.W., Venturino, M., Brown, S.W. & Lazar, J.D.
1997 ? Students Internal Distractors: Analgesia suggestion & guided imagery; External Distractors: Word memory & pursuit-rotor tasks.
Word Task / Visual Task
Internal and external distraction in the control of cold-pressor pain as a function of hypnotizability.
International Journal of Clinical and Experimental Hypnosis, 45(4), 433-446.
Christenfeld, N. 1997 72 Students P's shown light panel & told that when red light came on they should say "red" as quickly as possible, and when blue light came on say "blue". Low-distraction: P's told that one of the lights would come on every 30s; High-distraction: p's told that one of the lights would come on roughly every 5s, though any given interval between lights could be as small as 1s. Also told sometimes green light would also come on, & they should respond "red" to blue &
Visual Task Memory for pain and the delayed effects of distraction.
Health Psychology, 16(4), 327-330.
269
"blue" to red.Kassel, J.D. & Shiffman, S.
1997 124 Smokers & controls (students & general population)
P's asked to view a series of art slides & answer same four questions per, slide: "What do you think of the use of colors in this painting?", "What do you like best about this painting?", "What do you like least about this painting?", and "Is this the kind of painting you would tike to own yourself?"
Visual Task Attentional mediation of cigarette smoking's effect on anxiety.
Health Psychology, 16(4), 359-368.
Rose, M.P. & McGlynn, F.D.
1997 38 Students (Female snake & spider fearful respectively)
P’s listened to an audiotape about leadership and goal-setting during exposure and told to monitor the number of times two key-words were spoken.
Word Task Toward a standard experiment for studying post-treatment return of fear.
Journal of Anxiety Disorders, 11(3), 263-277.
Colwell, C.M. 1997 1 Adult female suffering from chronic pain due to multiple medical procedures for severe endometriosis
Music listening, imagery and relaxation, and vocal and instrumental rehearsal.
Music / Mental Imagery
Music as distraction and relaxation to reduce chronic pain and narcotic ingestion: A case study.
Music Therapy Perspectives, 15(1), 24-31.
Johnson, M.H. & Petrie, S.M.
1997 20 Adults (chronic low back pain sufferers)
P's were asked to repeat aloud a series of words presented at 30 words per minute. These were neutral 1 & 2 syllable words from the Rey Auditory Verbal Learning Test (1964) or commonly used nouns (e.g. tile, finger, farm, banana, church). P's asked to simultaneously view a video monitor showing a pair of words side by side which were replaced by another pair at 1-min intervals. At some point over the min the pair of words were on the screen and the same words would be mentioned in the shadowing word list. When a word was heard while appearing on the screen P's instructed not to shadow it.
Word Task The effects of distraction on exercise and cold pressor tolerance for chronic low back pain sufferers
Pain, 69(1-2), 43-48.
Brandon, T.H., Wetter, D.W. & Baker, T.B
1996 101 Students (Smokers) Oral word association test and the block design task, trace with a pen along the line of several circles and other shapes.
Word Task Affect, Expectancies, Urges, and Smoking: Do They Conform to Models of Drug Motivation and Relapse?
Experimental and Clinical Psychopharmacology, 4, 29-36.
Lassiter, G.D., Apple, K.J. & Slaw, R.D.
1996 423 Students P's informed to "please work on the following anagrams until you receive further instructions from the computer. Anagrams are words that are scrambled. Your task is to unscramble the words".
Word Task Need for cognition and thought-induced attitude polarization: Another look.
Journal of Social Behavior & Personality, 11(4), 647-665.
Blagden, J.C. & Craske, M.G.
1996 44 Students Imagination Tasks: Concentrating on various thoughts and ideas presented on 84 index cards which P's read slowly and silently to themselves. Passive Distraction: items included “the NBA play-offs will be in June” and “Harley-Davidson is a type of motorcycle”. Active Distraction: P's completed giant Q-sorts (Block, 1961) by sorting 34 index cards, one at a time, into seven ranked groups - P's ranked countries of the world in terms of industrialization.
Mental Imagery Effects of active and passive rumination and distraction: A pilot replication with anxious mood.
Journal of Anxiety Disorders, 10(4), 243-252.
Romero, A.A., Agnew, C.R. & Insko, C.A.
1996 159 Students Complete 20 increasingly difficult patterns of letters and numbers that couldn't be complete in the time allotted. They were instructed to complete as many as possible and to not linger on any one problem.
Word Task / Number Task
The cognitive mediation hypothesis revisited: An empirical response to methodological and theoretical criticism.
Personality and Social Psychology Bulletin, 22(7), 651-665.
Smith, J.T., Barabasz, 1996 27 Children (3-8 yrs) Prop introduced and discussed (pop-up distraction toy with loud Games (non- Comparison of hypnosis and Journal of Counseling Psychology,
270
A. & Barabasz, M. cancer or blood disorder sufferers
sounds) to be used during the procedure. Child selected his or her favorite pop-up toys from dozens provided by the trainer that were intended to have the capability to divert or redirect one's attention.
electronic) distraction in severely ill children undergoing painful medical procedures
43(2), 187-195.
Malone, A.B. 1996 40 Children (0-7 yrs) pediatric patients & controls
Received age appropriate live music, were encouraged to sing along, and given the opportunity to request favorite songs.
Music The effects of live music on the distress of pediatric patients receiving intravenous starts, venipunctures, injections, and heel sticks.
Journal of Music Therapy, 33(1), 19-33.
Sharpe, L., Tarrier, N., Schotte, D. & Spence, S.H.
1995 38 Adults (Gamblers - 13 problem; 12 high frequency; 13 low frequency)
Poker machine stimulus with instructions to count the number of occurrences of a payout.
Number Task The role of autonomic gambling arousal in problem gambling.
Addiction, 90(11), 1529-1540
Weisenberg, M., Tepper, I. & Schwarzwald, J.
1995 80 Adults Humorous stimuli consisted of a 7-min video series of slapstick scenes from an award winning, comedy, home-movie TV series.Repulsive video was a 7-min series of segments from a horror film chosen emphasized the 'blood and guts' in color. Neutral video consisted of a 7-min segment of a popular science series.
Film Humor as a cognitive technique for increasing pain tolerance
Pain, 63(2), 207-212.
Corrigan, P.W. & Addis, I.B.
1995 25 Adults (schizophrenics)
Digit Span Distraction Test (DSDT) - Audiotaped female voice read target numbers & male voice read distractor numbers. After each list, the tape recorder was shut off and subjects were instructed to write down, in order, as many numbers as they could remember.
Number Task Effects of extraneous stimuli on social cue perception in schizophrenia.
Psychiatry Research, 56(2), 111-120.
Fleming, K., Goldberg, T.E., Gold, J.M. & Weinberger, D.R.
1995 28 Adults (schizophrenics & controls)
Finger-tapping & Forward counting - P's requested to begin counting forwards from one; Backward counting - beginning with the number 100, P's instructed to count backwards by threes (“serial threes”).
Number Task Verbal working memory dysfunction in schizophrenia: Use of a Brown-Peterson paradigm.
Psychiatry Research, 56(2), 155-161.
Salkovskis, P.M. & Campbell, P.
1994 75 Students Thought suppression, mention control, and suppression under 3 different distraction conditions.
Thought Suppression
Thought suppression induces intrusion in naturally occurring negative intrusive
Behaviour Research and Therapy, 32(1), 1-8.
Furnham, A., Gunter, B. & Peterson, E.
1994 20 Students Programme played was a television drama: a videotaped extract from a well-known American soap opera (Knorrs Landing). This was low in physical action and perceptual salience (a high proportion of the programme time was spent with a character talking).
Film Television distraction and the performance of introverts and extroverts
Applied Cognitive Psychology, 8(7), 705-711.
Vessey, J.A., Carlson, K.L. & McGill, J.
1994 100 Children (3-12 yrs) Given a kaleidoscope to play with during procedure. Games (non-electronic)
Use of distraction with children during an acute pain experience.
Nursing Research, 43(6), 369-372.
Serper, M.R., Davidson, M. & Harvey, P.D.
1994 25 Adults (13 acute schizophrenic inpatients; 12 stable schizophrenic outpatients)
Digit-span distraction task. Number Task Attentional predictors of clinical change during neuroleptic treatment in schizophrenia.
Schizophrenia Research, 13(1), 65-71.
Seta, C.E., Hayes, N.S. & Seta, J.J.
1994 120 Students Told slides would contain either digits or letters and that they were to keep track of the number of digit slides they saw.
Number Task Mood, memory, and vigilance: The influence of distraction on recall and impression formation.
Personality and Social Psychology Bulletin, 20(2), 170-177.
Jagla, F. & Zikmund, V.
1994 20 ? Mental arithmetic and visual imagination. Number Task Influence of the distraction of visual attention on oculomotor manifestations of pursuing movement
Studia Psychologica, 36(1), 1-6.
271
Mobily, P.R., Herr, K.A. & Kelley, L.S.
1993 42 Nurses Relaxation, distraction, and guided imagery. Mental Imagery Cognitive-behavioral techniques to reduce pain: A validation study
International Journal of Nursing Studies, 30(6), 537-548
Nolen-Hoeksema, S. & Morrow, J.
1993 48 Students Eight minute focusing attention on current feeling states and personal characteristics (rumination condition) or on descriptions of geographic locations and objects (distraction condition).
Mental Imagery Effects of rumination and distraction on naturally occurring depressed mood
Cognition & Emotion, 7(6), 561-570.
Baker, G.A., Hanley, J.R. Jackson, H.F. Kimmance, S. & Slade, P.
1993 80 Adults (40 simulators; 40 amnesiacs)
Count backwards. Number Task Detecting the faking of amnesia: Performance differences between simulators and patients with memory impairment.
Journal of Clinical and Experimental Neuropsychology, 15(5), 668-684.
Vasterling, J., Jenkins, R.A., Tope, D.M. & Burish, T.G.
1993 60 Adults (cancer chemotherapy patients)
Played video games. Games (electronic) Cognitive distraction and relaxation training for the control of side effects due to cancer chemotherapy
Journal of Behavioral Medicine, 16(1), 65-80.
Cioffi, D. & Holloway, J.
1993 63 Students Asked to form a vivid mental picture of their rooms at home, to carefully notice the qualities of objects in it, and to fill their minds with the details of their rooms.
Mental Imagery Delayed costs of suppressed pain Journal of Personality and Social Psychology, 64(2), 274-282.
Mendolia, M. & Kleck, R.E.
1993 60 Students Watched a sequence of events in a neutral episode (a nature scene depicting pollination of cacti at the Saguaro National Monument) and then talked to the experimenter about the sequence of events that had occurred.
Film Effects of talking about a stressful event on arousal: Does what we talk about make a difference?
Journal of Personality and Social Psychology, 64(2), 283-292.
Curran, T. & Keele, S.W.
1993 57 Students & University Staff
Tone-counting task. Number Task Attentional and nonattentional forms of sequence learning.
Journal of Experimental Psychology: Learning, Memory, and Cognition, 19(1), 189-202.
Magill-Levreault, L. 1993 3 Patients with long-term life-threatening illnesses
Music therapy. Music Music therapy in pain and symptom management
Journal of Palliative Care, 9(4), 42-48.
Giolas, M.H. & Sanders, B.
1992 96 Students (Female) Imaginal distraction: Imagine your arm becoming numb and insensitive; Distraction: Concentrate on your breathing.
Mental Imagery Pain and suffering as a function of dissociation level and instructional set
Dissociation: Progress in the Dissociative Disorders, 5(4), 205-209.
McCaul, K.D., Monson, N. & Maki, R.H.
1992 214 Students Low-distraction task (easy) - little mental processing, p's simply indicated whether a number was present; Moderate-distraction (medium-difficulty) - some mental processing, p's classified numbers along a single dimension (odd-even); High-distraction (difficult) - more mental processing, p's classified numbers on two dimensions (odd-even & high-low).
Number Task Does distraction reduce pain-produced distress among college students?
Health Psychology, 11(4), 210-217.
Greene, P.G., Seime, R.J. & Smith, M.E.
1991 1 Adults (cancer chemotherapy patient)
Video distraction and relaxation. Film Distraction and relaxation training in the treatment of anticipatory vomiting: A single subject intervention.
Journal of Behavior Therapy and Experimental Psychiatry, 22(4), 285-290.
Grober, E. & Sliwinski, M.J.
1991 52 Elderly (Demented & non-demented)
Judging the similarity of pairs of letters. Word Task Dual-task performance in demented and nondemented elderly.
Journal of Clinical and Experimental Neuropsychology, 13(5), 667-676.
Williams, S.L & Kinney, P.J.
1991 64 Students Overt performance distraction, verbal–imaginal distraction, relaxation.
Mental Imagery Performance and nonperformance strategies for coping with acute pain: The role of perceived self-efficacy, expected outcomes, and attention.
Cognitive Therapy and Research, 15(1), 1-19.
Coren, S. & Aks, D.J. 1991 315 Students Environmental distraction: Visual & auditory distraction. Visual Task / Auditory Task
Prediction of task-related arousal under conditions of environmental distraction.
Journal of Applied Social Psychology, 21(3), 189-197.
272
Anderson, R.A., Baron, R.S. & Logan, H.
1991 38 Adult (Dental Patients)
Incidental music during dental procedure; music coupled with suggestions that music would help reduce stress.
Music Distraction, control, and dental stress Journal of Applied Social Psychology, 21(2), 156-171.
Aks, D.J. & Coren, S. 1990 272 Students Speeded visual search task: P's performed visual search task, and had auditory distraction of 18 meaningful sounds (e.g., baby crying, car crashing).
Visual Task / Auditory Task
Is susceptibility to distraction related to mental ability?
Journal of Educational Psychology, 82(2), 388-390.
Marmurek, H.H., 1990 36 Students Counting task. Number Task The dissociation of impression formation and person memory: The effects of processing resources and trait favorableness.
Journal of Research in Personality, 24(2), 191-205.
Avants, S.K., Margolin, A. & Salovey, P.
1990 100 Students (1) Progressive muscle relaxation; (2) Distraction imagery; (3) Focused imagery; (4) Listening to music.
Mental Imagery / Music
Stress management techniques: Anxiety reduction, appeal, and individual differences.
Imagination, Cognition and Personality, 10(1), 3-23.
Williams, R.D., Riels, A.G. & Roper, K.A.
1990 56 Students Mental arithmetic task and ‘Simon Says’ game. Number Task / Games (electronic)
Optimism and distractibility in cardiovascular reactivity.
The Psychological Record, 40(3), 451-457.
Shimizu, K., Hatayama, T. & Ohyama, M.
1990 16 Students (Female) Asked to recall a small number of letters presented. Word Task Variation in time threshold of experimental pain: Its relation to attention distraction.
Tohoku Psychologica Folia, 49, 97-105.
Devine, D.P. & Spanos, N.P.
1990 96 Students Non-imaginal Distraction: P's informed that they could reduce their pain if they distracted themselves by counting backward from 1,000 by sevens during the immersion. Imaginal Distraction: P's told that they could reduce their pain by imagining that they were at a carnival riding an old-fashioned merry-go-round. They were instructed to distract themselves from the pain by concentrating on the details of their imagined scene (e.g., the bright colours, ornate carvings).
Number Task / Mental Imagery
Effectiveness of maximally different cognitive strategies and expectancy in attenuation of reported pain.
Journal of Personality and Social Psychology, 58(4), 672-678.
Marino, J., Gwynn, M.I. & Spanos, N.P.
1989 80 Students Letter shadowing: P's instructed to listen to and repeat aloud letters presented to them through headphones at the rate of three letters every 2 s. The letters were presented in random order.
Word Task Cognitive mediators in the reduction of pain: The role of expectancy, strategy use, and self-presentation.
Journal of Abnormal Psychology, 98(3), 256-262.
Allen, K.D., Danforth, J.S. & Drabman, R.S.
1989 9 Adults (Patients undergoing hyperbaric oxygen therapy)
P's selected a feature film to watch. Film Videotaped modeling and film distraction for fear reduction in adults undergoing hyperbaric oxygen therapy.
Journal of Consulting and Clinical Psychology, 57(4), 554-558.
Nakajima, Y. & Sato, K.
1989 42 Students Easy, medium and difficult summation task. Number Task Distractor difficulty and the long-term recency effect.
American Journal of Psychology, 102(4), 511-521.
Stark, L.J., Allen, K.D., Hurst, M., Nash, D.A. et al.
1989 4 Children (Male dental patients: 4 yrs 6m - 7 yrs 3m)
Four posters from the Peabody Language Development Kit and 13-min audio recorded stories about the posters.
Story listening Distraction: Its utilization and efficacy with children undergoing dental treatment.
Journal of Applied Behavior Analysis, 22(3), 297-307.
Hong, O.P. & Harrod, W.J.
1988 65 Students Match the correct captions to a set of eight cartoons, and then compose their own captions for a set of six other cartoons.
Visual Task The role of reasons in the ingroup bias phenomenon.
European Journal of Social Psychology, 18(6), 537-545.
Wostratzky, S., Braun, E. & Roth, N.
1988 80 Dental Patients Passive and active distraction by music. Music The influence of distraction on coping with stress in dentistry.
Activitas Nervosa Superior, 30(2), 120-121.
Kuttner, L. 1988 25 Children (Leukemia patients: 3 yrs - 6 yrs 11m)
Favorite-story hypnotic technique. Story listening Favorite stories: A hypnotic pain-reduction technique for children in acute pain.
American Journal of Clinical Hypnosis, 30(4), 289-295.
Becker, M.A. & 1988 118 Students (Male) Simple or complex visual numbers task. Number Task Type A behavior, distraction, and Journal of Social & Clinical Psychology,
273
Byrne, D. sexual arousal. 6(3-4), 472-481.Harvey, P.D., Earle-Boyer, E.A. & Levinson, J.C.
1987 77 Manic (n = 26) schizophrenic (n = 26) normal (n = 25)
Serial Recall Tasks: Five target digits presented in a female voice, with four irrelevant digits presented in an opposite-sexed voice in the 2-second interval between the presentation of each target digit.
Number Task Cognitive Deficits and Thought Disorder: A Retest Study.
Schizophrenia Bulletin, 14(1), 57-66.
Fowler-Kerry, S. & Lander, J.R.
1987 200 Children (4.5 – 6.5 yrs)
Music distraction. Music Management of injection pain in children.
Pain, 30(2), 169-175.
Redd, W.H., Jacobsen, P.B., Die-Trill, M., Dermatis, H., McEvoy, M. & Holland, J.C
1987 26 Children (Cancer patients)
Playing commercially available video games (e.g. Frogger, Pitfall). Games (electronic) Cognitive/attentional distraction in the control of conditioned nausea in pediatric cancer patients receiving chemotherapy.
Journal of Consulting and Clinical Psychology, 55(3), 391-395.
Fennell, M.J., Teasdale, J.D. Jones, S. & Damlé, A.
1987 30 Adults (Depressed patients)
Slide-description task. Visual Task Distraction in neurotic and endogenous depression: An investigation of negative thinking in major depressive disorder.
Psychological Medicine, 17(2), 441-452.
Dubreuil, D.L., Endler, N.S. & Spanos, N.P.
1987 144 Students Letter shadowing. Word Task Distraction and redefinition in the reduction of low and high intensity experimentally-induced pain.
Imagination, Cognition and Personality, 7(2), 155-164.
Algarabel, S. & Sanmartín, J.
1987 66 Students Studied lists of 30 Spanish words presented at 100 msec, 500 msec or 1000 msec while counting backward.
Number Task Recognition memory search strategies as a function of confidence level of the answer.
Psicológica, 8(2), 105-120.
Wikstrom, P-O. 1986 54 Dental Patients Auditory distraction (AD) and hypnotically induced music hallucinations.
Music The use of auditory distraction and music hallucinations in dental practice.
Australian Journal of Clinical & Experimental Hypnosis, 14(2), 125-132.
Walker, E. & Harvey, P.
1986 67 45 schizophrenic 22 manic patients
Digit-span task. Number Task Positive and negative symptoms in schizophrenia: Attentional performance correlates.
Psychopathology, 19(6), 294-302.
Knight, R.G., Youard, P.J. & Wooles, I.M.
1985 42 Aduts (24 schizophrenics & 18 controls)
Three irrelevant elements were added to neutral stimuli and the p's task was to determine which group of letters was the larger.
Word Task Visual information-processing deficits in chronic schizophrenic subjects using tasks matched for discriminating power.
Journal of Abnormal Psychology, 94(4), 454-459.
Boski, P. 1985 160 Students (Male) Digit substitution task: 24 arithmetic operations of addition & subtraction of three-digit numbers that were written in a symbolic code. Distraction-relaxation: Pop music was played from a tape that was intended to attentuate p's. The music was on during the whole experimental session except for the period of the main task performance and was played apparently for the experimenter’s self indulgence, as he was openly complaining about the boredom in his work.
Number Task / Music
Causes and affects under manipulated arousal and achievement-related outcomes.
European Journal of Social Psychology, 15(3), 281-297.
Elbert, T., Hommel, J. & Lutzenberger, W.
1985 12 Students (Male) Listening to radio. Music The perception of Necker cube reversal interacts with the Bereitschaftspotential.
International Journal of Psychophysiology, 3(1), 5-12.
Farthing, G.W, Venturino, M. & Brown, S.W.
1984 96 Students Instructed that the (tape-recorded) experimenter would read a list of words and that they should concentrate on the words and try to remember all of them "Your memory for the words will be tested after your hand has been removed from the water You should silently repeat the words to yourself as we go along Whenever you
Memory Task Suggestion and distraction in the control of pain: Test of two hypotheses.
Journal of Abnormal Psychology, 93(3), 266-276.
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hear me say "report1", then quickly give your pain rating and go right back to listening to the words and repeating them to yourself".
Spanos, N.P., McNeil, C., Gwynn, M.I. & Stam, H.J.
1984 84 Students Word shadowing: P's listened to list of monosyllabic words presented at 74 words p/min. & instructed to repeat back each word verbatim immediately after presentation P's informed that accurate shadowing was their primary concern.
Word Task Effects of suggestion and distraction on reported pain in subjects high and low on hypnotic susceptibility.
Journal of Abnormal Psychology, 93(3), 277-284.
Brix, R. 1984 100 ? Reading a newspaper. Reading The influence of attention on the auditory brain stem evoked responses: Preliminary report
Acta Oto-Laryngologica, 98(1-2), 89-92.
Faust, J, & Melamed, B.G.
1984 66 Children & Adolescents (4–17 yrs) pediatric surgery patients
Viewed a 10-min non-hospital-relevant film. Film Influence of arousal, previous experience, and age on surgery preparation of same day of surgery and in-hospital pediatric patients.
Journal of Consulting and Clinical Psychology, 52(3), 359-365.
Greenstein, S.M. 1984 60 Students (Female) Shown pleasant and unpleasant slide scenes and given a recall task. Visual Task Pleasant and unpleasant slides: Their effects on pain tolerance.
Cognitive Therapy and Research, 8(2), 201-209.
Gregg, V.H. & Gardiner, J.M.
1984 32 Students Shown a 3-digit number, which they immediately and silently mouthed and began counting backward by 3's silently mouthing each number.
Number Task Phonological similarity and enhanced auditory recency in longer-term free recall.
The Quarterly Journal of Experimental Psychology A: Human Experimental Psychology, 36(1-A), 13-27.
Reisberg, D. & Shaughnessy, M.
1984 16 Students Mental arithmetic task. Number Task Diverting subjects' concentration slows figural reversals.
Perception, 13(4), 461-468.
Gathercole, S.E., Gregg, V.H. & Gardiner, J.M.
1983 48 Students Visual Distractor: Following an unfilled interval, p's had to copy down 4 digits printed on a single card placed in front of them. Auditory Distractor: Experimenter read aloud 4 digits at a normal reading rate and the subjects wrote them down.
Number Task Influences of delayed distraction on the modality effect in free recall.
British Journal of Psychology, 74(2), 223-232.
Ahles, T.A., Blanchard, E.B. & Leventhal, H.
1983 124 Students (Male) Instructed to name their high school courses and teachers. Memory Task Cognitive control of pain: Attention to the sensory aspects of the cold pressor stimulus.
Cognitive Therapy and Research, 7(2), 159-177.
Wardle, J. 1983 73 Adult & Adolescent (Dental Patients)
Visually interesting stimulus projected on the ceiling. Visual Task Psychological management of anxiety and pain during dental treatment.
Journal of Psychosomatic Research, 27(5), 399-402.
Housner, L.D. & Griffey, D.
1983 36 Students (Male) Competing visualization task. Mental Imagery Effects of imagery ability and instructions on recall of information on spatial location
Perceptual and Motor Skills, 57(3, Pt 2), 1087-1092.
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Appendix 14 – Study 2: Poster advertisement
Want to take part in a…
Volunteers are needed to participate in a study looking at different types of
distraction
This will involve a 40 minute session at the University or another convenient location.
You’ll be asked to take part in 6 simple 5 minute tasks and then fill out a questionnaire about your experiences.
For more information without obligation, please call Sally on:
07815 ****** or email [email protected] (I will call you back)
This study has been reviewed and has been given a favourable ethical opinion by the University of Surrey Ethics
Committee
Appendix 15 – Study 2: Post distraction task questionnaire
276
Please circle your response below:
Not at all Somewhat Extremely
H How difficult did you find the task? 1 2 3 4 5 6 7
How relaxing did you find the task? 1 2 3 4 5 6 7
How challenging did you find the task?
1 2 3 4 5 6 7
How stressed did the task make you feel?
1 2 3 4 5 6 7
How much did the task take over your attention?
1 2 3 4 5 6 7
How calm did the task make you feel?
1 2 3 4 5 6 7
How distracted from your thoughts did the task make you feel?
1 2 3 4 5 6 7
How pressured did the task make you feel?
1 2 3 4 5 6 7
How boring did you find the task? 1 2 3 4 5 6 7
How conscious were you of doing the task?
1 2 3 4 5 6 7
How fatigued did the task make you feel?
1 2 3 4 5 6 7
How much did your mind wander whilst performing the task?
1 2 3 4 5 6 7
How much did you enjoy doing the task?
1 2 3 4 5 6 7
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Appendix 16 – Study 2: Participant information sheet
You are being invited to take part in a research study. Before you decide to take part it is important that you understand why the research is being done and what it will involve. Please take time to carefully read the following information and ask if anything is not clear.
What is the purpose of the study?The main aim of this research study is to examine your experiences of performing different distracting tasks. These include: mentally scanning different body areas, listening to someone reading a passage of text or a story, listening to a piece of music, playing a computer game and performing a computer based arithmetic task. Each task lasts for 5 minutes.
What will you be asked to do?You will be asked to come to a lab in the psychology department or another convenient location, where if you are happy to participate in the study, you will be asked a few background questions and then begin taking part in the distraction tasks.
You will be asked to listen to the four 5 minute audio recordings, asked to play the 5 minute computer game and complete the 5 minute arithmetic task - the tasks will be presented to you in a randomly allocated order.
At the end of each task, you will be asked a series of questions about how performing that specific task made you feel. Once all of the tasks are completed you will be asked a few more questions about yourself, and then your participation is finished.
Are there any risks involved with taking part in the study? There are no known risks of taking part in the study.
Are you eligible to join the study?You are eligible to take part in the study if you are aged 18 to 65 years, you are not pregnant or receiving treatment for a mental health condition. All information which is collected during the course of the research will be kept strictly confidential. If you decide to take part you will be given this information sheet to keep and you will be asked to sign a consent form, which you will keep. You will be free to withdraw from the study at any time and without giving a reason.
Thank you for taking the time to read this information sheet. If you have any queries or concerns please phone Sally on 07815 ****** or e-mail: [email protected] who will do her best to answer your questions.
This study has been reviewed and has been given a favourable ethical opinion by the University ofSurrey Ethics Committee
278
Appendix 17 – Study 2 & 3: Participant consent form
I the undersigned agree to take part in the distraction study.
I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.
I agree to comply with any instruction given to me during the study and to co-operate fully with the investigators. I shall inform them immediately if I suffer any deterioration of any kind in my health or well-being, or experience any unexpected or unusual symptoms.
I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998). I agree that I will not seek to restrict the use of the results of the study on the understanding that my anonymity is preserved.
I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.
I understand that in the event of my suffering a significant and enduring injury (including illness or disease) as a direct result of my participation in the study, compensation will be paid to me by the University, subject to certain provisos and limitations. The amount of compensation will be appropriate to the nature, severity and persistence of the injury and will, in general terms, be consistent with the amount of damages commonly awarded for similar injury by an English court in cases where the liability has been admitted
I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.
Name of volunteer (BLOCK CAPITALS) .........................................................
Signed ...................................................
Date ......................................
Name of researcher/person taking consent (BLOCK CAPITALS)...............................................
Signed .........................................
...............
Date .......................................
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Appendix 18 – Study 2: Demographics questionnaire
How old are you? I am …………years
Are you Male or Female (please circle)
What is your ethnic group? (please tick one box only)
WhiteBlack AfricanBlack CaribbeanAny other Black backgroundWhite & Black CaribbeanWhite & Black AfricanWhite & AsianAny other mixed backgroundIndianBangladeshiPakistaniAny other Asian backgroundChineseAny other ethnic group
What is your usual occupation? (please tick one box only)
Professional/managerClerical/secretarialSkilled manualUnskilled/semi-skilled manualHome keeper/makerStudent (see below)
If a student, what is your current level of study? (please tick one box only)
Undergraduate – Year 1Undergraduate – Year 2Undergraduate – Year 3Undergraduate – Year 4Post Graduate - MScPost Graduate – MPhil/PhDOther (please specify) below:
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Appendix 19 – Study 2: Individual distraction item figures
Individual figures showing separate lines for each item on the composite distraction
questionnaire measures of attention, difficulty and relaxation:
Body scan
Selborne Audio book
Classical music
Game PVSAT2.00
3.00
4.00
5.00
6.00
7.00Attention taking
Distraction from thoughts
Conscious of thoughts
Rat
ings
of a
ttent
ion
expe
nditu
re
Figure 1. Ratings of separate attention expenditure items by task
Body scan
Selborne Audio book
Classical music
Game PVSAT1.00
2.00
3.00
4.00
5.00
6.00 Mind wandering
Boredom
Rat
ings
of m
ind
wan
derin
g &
bor
edom
281
Figure 2. Ratings of mind wandering and boredom items by task3
Body scan
Selborne Audio book
Classical music
Game PVSAT1.00
2.00
3.00
4.00
5.00
6.00 Challanging
Difficult
Pressurising
Stressful
Rat
ings
of t
ask
diffi
culty
Figure 3. Ratings of separate difficulty items by task
Body scan Selborne Audio book
Classical music
Game PVSAT1.00
2.00
3.00
4.00
5.00
6.00 Relaxing
Calming
Rat
ings
of r
elax
atio
n
Figure 4. Ratings of separate relaxation items by task
3 These two items are presented separately from the other attention items for clarity.282
Appendix 20 – Study 3: Ethics approval
Sally Gillison PsychologyFAHS
Ethics Committee
05 August 2008
Dear Sally
Investigation to explore the effect of guided bodyscanning versus two distraction tasks on nicotine withdrawal symptoms and cravings in temporarily abstinent smokers.EC/2008/50/FAHS
On behalf of the Ethics Committee, I am pleased to confirm a favourable ethical opinion for the above research on the basis described in the submitted protocol and supporting documentation.
Date of confirmation of ethical opinion: 5 August 2008
The final list of documents reviewed by the Committee is as follows:
Document DateSummary of the project 5 Aug 08Detailed project 5 Aug 08Information sheet 5 Aug 08Consent form 5 Aug 08Questionnaire/Interview schedule 5 Aug 08
This opinion is given on the understanding that you will comply with the University's Ethical Guidelines for Teaching and Research.
The Committee should be notified of any amendments to the protocol, any adverse reactions suffered by research participants, and if the study is terminated earlier than expected with reasons.
You are asked to note that a further submission to the Ethics Committee will be required in the event that the study is not completed within five years of the above date.
Please inform me when the research has been completed.
Yours sincerely
Aimee Cox (Miss)Secretary, University Ethics Committee Registry
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cc: Professor T Desombre, Chairman, Ethics Committee
Appendix 21 – Study 3: Poster advertisement Are you a
Volunteers are needed to participate in a study looking at new ways to reduce
cigarette cravings.
This will involve a 10 minute session at the office or in another convenient location.
In addition, there will be one session of 30 minutes to complete a simple audio file listening task. Again, this can be at the office or another convenient location.
A payment of £10 will be made to cover any inconvenience and expenses.
For more information without obligation, please e-mail Sally on:
Department of Psychology, University of Surrey, Guildford, GU2 5XH
284
This study has been reviewed and has been given a favourable ethical opinion by the University of Surrey Ethics
Committee
Appendix 22 – Study 3: Participant information sheet
You are being invited to take part in a research study. Before you decide to take part it is important that you understand why the research is being done and what it will involve. Please take time to carefully read the following information and ask if anything is not clear.
What is the purpose of the study?The main aim of this research study is to examine how your cravings for cigarettes change following 10 minutes of scanning different body areas, 10 minutes of listening to an audiobook story or 10 minutes of listening to some classical music.
What will you be asked to do?You will be asked to attend a total of two assessments for a total of around 40 minutes. These can either be at your place of work or, another convenient location. The first visit will take about 10 minutes and involve checking how much you smoke and asking a few background questions. You will then be asked not to smoke at all, or use any other nicotine based product from 10pm that evening until you have completed the experiment the following day. This is essential for the study.
At the second assessment the following morning, you will be seen for approximately 30 minutes. Initially, you will be asked to blow into a machine that will confirm that you have not smoked, and then to rate your current cigarette cravings. You will be randomly allocated to and perform one of the three tasks, and then be asked about your cravings immediately after the task, and every five minutes thereafter for a total of 15 minutes.
You have an equal chance of being allocated to any one of the three conditions.
Are there any risks involved with taking part in the study? There are no known risks of taking part in the study.
Are you eligible to join the study?You are eligible to take part in the study if you are aged 18 to 65 years, you have smoked 10 or more cigarettes a day for at least three years and you are not pregnant or receiving treatment for a mental health condition. All information collected during the course of the research will be kept strictly confidential. If you decide to take part you will be given this information sheet to keep and you will be asked to sign a consent form, which you will keep. You will be free to withdraw from the study at any time and without giving a
285
reason. Thank you for taking the time to read this information sheet. If you have any queries or concerns please phone Sally on 07815 ****** or e-mail: [email protected] who will do her best to answer your questions.
286
Appendix 23 – Study 3: Participant feedback questionnaire
For these three questions please circle one response only:
1. How useful did you find the intervention for relieving your desire to smoke?
Not at all useful
Slightlyuseful
Moderatelyuseful
Veryuseful
Extremelyuseful
2. Would you recommend this strategy to smokers who are trying to quit?
Definitely would not
recommend
Probablywould not
recommendNot sure
Probably would
recommend
Definitely would
recommend
3. How effective do you think this strategy would be for most smokers
Not at all effective
Slightly effective
Moderately effective
Veryeffective
Extremely effective
4. How familiar were you with the audio? Not at all familiar
Slightly familiar
Moderately familiar
Veryfamiliar
Extremely familiar
5. How much did you enjoy listening to the audio?
Not at all enjoyable
Slightly enjoyable
Moderately enjoyable
Veryenjoyable
Extremely enjoyable
Thank you for completing this questionnaire
286
Appendix 24 – Study 1 & 3: Smoking cessation resources
To find out more about local help to quit smoking call 0845 602 3608
You might find the following National Help lines and sources of advice and information useful:
FREE NHS Smoking Helpline 0800 169 0 169
www.givingupsmoking.co.ukwww.ash.org.ukwww.bhf.org.uk/smoking/
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