Elsevier

Addictive Behaviors

Volume 39, Issue 11, November 2014, Pages 1682-1689
Addictive Behaviors

Delay discounting rates: A strong prognostic indicator of smoking relapse

https://doi.org/10.1016/j.addbeh.2014.04.019Get rights and content

Highlights

  • We compared the ability of selected factors to predict days to smoking relapse.

  • Delay discounting rates had stronger associations with days to relapse than other factors.

  • Delay discounting added to variance associated with dependence and stress levels.

  • Delay discounting rates are uniquely associated with relapse.

  • Delay discounting is a new target for enhancing treatment for tobacco dependence.

Abstract

Background

Recent evidence suggests that several dimensions of impulsivity and locus of control are likely to be significant prognostic indicators of relapse.

Method

One-hundred and thirty-one treatment seeking smokers were enrolled in six weeks of multi-component cognitive-behavioral therapy with eight weeks of nicotine replacement therapy.

Analysis

Cox proportional hazard regressions were used to model days to relapse with each of the following: delay discounting of $100, delay discounting of $1000, six subscales of the Barratt Impulsiveness Scale (BIS), Rotter's Locus of Control (RLOC), Fagerstrom's Test for Nicotine Dependence (FTND), and the Perceived Stress Scale (PSS). Hazard ratios for a one standard deviation increase were estimated with 95% confidence intervals for each explanatory variable. Likelihood ratios were used to examine the level of association with days to relapse for different combinations of the explanatory variables while accounting for nicotine dependence and stress level.

Results

These analyses found that the $100 delay discounting rate had the strongest association with days to relapse. Further, when discounting rates were combined with the FTND and PSS, the associations remained significant. When the other measures were combined with the FTND and PSS, their associations with relapse non-significant.

Conclusions

These findings indicate that delay discounting is independently associated with relapse and adds to what is already accounted for by nicotine dependence and stress level. They also signify that delay discounting is a productive new target for enhancing treatment for tobacco dependence. Consequently, adding an intervention designed to decrease discounting rates to a comprehensive treatment for tobacco dependence has the potential to decrease relapse rates.

Introduction

Tobacco use is the greatest cause of preventable death and disease in the United States (CDC, 2005, Mokdad et al., 2004). At present, 45 million, fully 1 in 5 Americans, smoke daily (CDC, 2011a). Even though 70% of smokers desire to quit smoking (CDC, 2011b) and about half of all smokers make a quit attempt each year (CDC, 2011b), 94% of those who attempt to quit will relapse within 6 months (CDC, 2011b, Fiore et al., 2008). Even with intensive multi-component combination treatment, at least 70% of smokers relapse within 12 months (Fiore et al., 2008). Substantial progress has been made in addressing factors identified by well-established, strong prognostic indicators such as nicotine dependence and stress level (Fiore et al., 2008). However, the identification of additional factors would provide new targets for enhancing treatment for tobacco dependence and reducing relapse rates. Evidence is mounting for the prospective role of delay discounting, certain aspects of trait impulsiveness, and locus of control as indicators of relapse to smoking and potential targets for enhancing the treatment of tobacco dependence (MacKillop and Kahler, 2009, Sheffer et al., 2012, Stanger et al., 2012, Yoon et al., 2007).

Impulsivity is a multi-dimensional construct often associated with nicotine dependence and smoking (Chase and Hogarth, 2011, Rezvanfard et al., 2010, Sheffer et al., 2012); however, the results supporting impulsivity as a prognostic indicator of relapse have been mixed (Powell, Dawkins, West, & Pickering, 2010). Impulsivity is generally thought to subsume many aspects of reward seeking and disinhibition (Flory and Manuck, 2009, Mitchell, 1999) as well as several aspects of what is often considered trait impulsiveness (Lane et al., 2003, Meda et al., 2009, Reynolds et al., 2006). Consistent with this conceptualization, trait impulsiveness is positively associated with the subjective rewarding effects of nicotine (Perkins et al., 2008) as well as explicit expectancies about nicotine reward (Doran, McChargue, & Cohen, 2007). Some have found trait impulsiveness to be positively associated with another dimension of impulsivity, delay discounting (Audrain-McGovern et al., 2009, Flory and Manuck, 2009, Powell et al., 2010).

Smoking provides a variety of immediate rewards (e.g., stress relief, relief from withdrawal symptoms) of value to smokers for limited immediate costs; however, the long-term costs to health, relationships, and long life are substantial. Delay discounting is the degree (i.e., the rate) to which one discounts or de-values a reward as a function of the amount of time to the receipt of that reward. Unsurprisingly, smokers discount the value of future health more than nonsmokers, but smokers also discount the value of monetary rewards more than nonsmokers (Baker et al., 2003, Bickel et al., 1999, Bickel and Yi, 2008, Mitchell, 1999, Reynolds, 2004, Reynolds et al., 2003). Higher delay discounting rates are also associated with higher nicotine dependence levels (Sweitzer, Donny, Dierker, Flory, & Manuck, 2008) and a decreased likelihood of long-term abstinence after treatment for tobacco dependence (Krishnan-Sarin et al., 2007, MacKillop and Kahler, 2009, Sheffer et al., 2012, Stanger et al., 2012, Yoon et al., 2007), but are not always strongly associated with dimensions of trait impulsiveness among smokers (Sheffer et al., 2012).

Locus of control is the degree to which one believes that reinforcement or rewards are contingent upon internal versus external factors (Rotter, 1966). Individuals with an internally-focused locus of control believe that reinforcement is contingent upon their own efforts and tend to be less impulsive, more future-oriented, report lower levels of stress, and discount less than externally-focused individuals, while individuals with an externally-focused locus of control believe that reinforcement is contingent upon luck, fate, or powerful others (Erikson and Roberts, 1971, Platt and Eisenman, 1968, Plunkett and Buehner, 2007, Rotter, 1966, Srinivasan and Tikoo, 1992). An internally focused locus of control is a positive prognostic indicator for maintaining abstinence from smoking (Gregor et al., 2008, McKenna and Higgins, 1997, Rosenbaum and Argon, 1979, Sheffer et al., 2012). Externally-focused smokers report greater levels of stress (Sheffer et al., 2012).

Perceived stress level is a well-established prognostic indicator of relapse as well as a frequently mentioned barrier to quitting (Fiore et al., 2008). Stress management is, in fact, an evidence-based component in comprehensive tobacco dependence treatment programs (Fiore et al., 2008). We have found weak associations among smokers in previous work between stress level and delay discounting as well as between stress level and the dimensions of trait impulsiveness assessed by the Barratt Impulsiveness Scale with the exception of attentional/cognitive impulsiveness (Sheffer et al., 2012). Locus of control, however, is conceptually and empirically associated with stress level. Perceived stress and locus of control both incorporate the concept of perceived control over stressful events. Less perceived control over stressful events contributes to greater levels of stress (Wetter et al., 1994), and an externally-focused locus of control (Rotter, 1966). In some instances, locus of control appears to moderate the relationship between external events and the experience of stress (Carter, Mollen, & Smith, 2014).

Given the tobacco-related disease burden, improving relapse rates has the potential to significantly impact public health. There are a modest number of studies that examine delay discounting rates, trait impulsiveness, and locus of control as prognostic indicators of relapse to smoking, and there is growing support for incorporating these new measures into the assessment and treatment of tobacco dependence and other addictions (Sheffer et al., 2012, Bickel et al., 2014). Arguably, in order to justify these efforts, the strengths of the associations among these measures with relapse need to be at least commensurate with well-established indicators such as nicotine dependence and stress levels. These measures would also need to add to what is already provided by these well-established indicators. At present, there are no studies in which these measures have been compared with nicotine dependence and/or stress or other well-established indicators.

We compared the relative strengths of associations among delay discounting, dimensions of trait impulsiveness from the Barratt Impulsiveness Scale-11 (BIS-11), locus of control, nicotine dependence, and perceived stress with days to relapse among smokers after an intensive multi-component cognitive-behavioral treatment for tobacco dependence. Although impulsivity is often associated with nicotine dependence, there are mixed findings with regard to its role as a prognostic indicator of relapse (Powell et al., 2010); therefore, we hypothesized that higher levels of trait impulsiveness would not be strongly associated with relapse. Given the consistent, strong relationship between delay discounting rates and abstinence rates in other studies (Krishnan-Sarin et al., 2007, MacKillop and Kahler, 2009, Sheffer et al., 2012, Stanger et al., 2012, Yoon et al., 2007), we hypothesized that higher delay discounting rates would be a strong indicator of relapse, perhaps as strong as nicotine dependence, a well-established indicator. Because stress and locus of control are conceptually and empirically related, we hypothesized that their associations with relapse would be strong, but would not differ significantly from each other. Further, given the conceptual and empirical evidence, we hypothesized that delay discounting and trait impulsiveness, but not locus of control would remain associated with relapse when combined with nicotine dependence and perceived stress in the analyses.

Section snippets

Participants

Participants were aged 18 years or older, smoked 10 or more cigarettes per day and were recruited by referral from medical center campus tobacco treatment services, word-of-mouth, and local advertisements. For the purposes of this study, only those participants who reached the treatment quit date, the third treatment session, were included. Individuals who were pregnant or lactating, already using medications for smoking cessation (i.e., bupropion, varenicline, nicotine replacement, etc.) or

Participants

One-hundred and thirty-one (n = 131) participants were enrolled in this study; n = 100 participants attended at least one session of treatment; and n = 90 participants attended at least three sessions of treatment (i.e., made it to the scheduled quit day). Participants who reached the quit day were 47% male, 57% partnered, 77% white, 13% African American, and 10% other (American Indian or Alaskan Native, Pacific Islander, multi-racial). They had a mean age of 47.5 (SD 12.7), a median annual household

Discussion

We compared the relative strengths of associations among delay discounting rates, dimensions of trait impulsiveness from the BIS-11, locus of control, nicotine dependence, and stress level with days to relapse among smokers after an intensive multi-component cognitive-behavioral treatment for tobacco dependence. Our findings indicate that delay discounting of $100 demonstrated the strongest association with relapse and that measures of delay discounting and trait impulsiveness have stronger

Role of funding sources

The conduct of this study and the preparation of this manuscript were supported by grants from the National Institutes of Health including the National Institute for Drug Abuse (NIDA 1 RO1 DA022386-01), National Institute on Alcohol Abuse and Alcoholism (NIAAA 5K23AA016936), and the National Center for Research Resources (NCRR020146), and the National Center for Advancing Translational Science (UL1TR000039). These funding sources had no involvement in the study design, collection, analysis, or

Contributors

Drs. Bickel, Landes, and Sheffer designed the study, wrote the protocol, and developed the first draft of the manuscript. Dr. Christensen contributed to all drafts of the manuscript and conducted preliminary analyses. Drs. Carter and Christensen and Lisa Jackson contributed to the conduct of the study. Dr. Landes conducted the statistical analysis. Drs. Bickel, Landes, Sheffer, and Christensen contributed to the interpretation of the results. All authors contributed to the manuscript as it

Conflict of interest

Dr. Sheffer received research funding from Pfizer, Inc. Dr. Bickel is a principal in HealthSIm LLC. All other authors declare no conflicts of interest.

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