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Exercise as a Smoking Cessation Aid
C H A P T E R
55 Exercise as a Smoking Cessation Aid Scott Rollo, Wuyou Sui, Harry Prapavessis Faculty of Health Sciences, School of Kinesiology, The University of Western Ontario, London, ON, Canada
Abbreviations CBT NRT PA RCT
cognitive behavioral therapy nicotine replacement therapy physical activity randomized controlled trial
55.1 INTRODUCTION Tobacco smoking is the leading cause of preventable deaths worldwide, with over 6 million deaths each year attributable to tobacco use (WHO, 2017). It has been well established that smoking is detrimental to one’s health and an important modifiable risk factor for numerous chronic diseases (USDHHS, 2010). Although it is declining worldwide, the prevalence of tobacco smoking is still over 1.1 billion people globally (WHO, 2017). Smoking cessation at any age is associated with numerous health benefits and diminished risk of developing smokingrelated diseases, such as lung cancer, heart attack, stroke, and chronic lung disease (USDHHS, 1990). Unfortunately, smoking cessation is difficult. Despite the known health consequences, many smokers find it challenging to quit smoking, and failure rates are consistently high. Among adult smokers who quit smoking without formal treatment, only 3%–5% are successfully tobacco-free 1 year following their quit attempt (Hughes, Keely, & Naud, 2004). Low quit rates can be explained by a number of factors including the highly addictive properties of nicotine found within cigarettes (Hirschhorn and World Health Organization, 2009), heightened cravings and withdrawal symptoms (Allen, Bade, Hatsukami, & Center, 2008), weight gain associated with smoking cessation (Klesges et al., 1988), and the learned and reinforcing behavior of smoking (CADTH, 2014). Numerous pharmacological (e.g., nicotine replacement therapies (NRT), nicotine gum, inhaler, nasal spray, transdermal patch, and lozenge; see Figs. 55.1 and 55.2) and behavioral smoking cessation treatment (e.g.,
Neuroscience of Nicotine https://doi.org/10.1016/B978-0-12-813035-3.00055-1
cognitive behavioral therapy (CBT)) options exist to aid in the cessation process, promote cessation maintenance, and prevent smoking relapse (Collins, Witkiewitz, Kirouac, & Marlatt, 2010). While the combination of the abovementioned interventions has shown to improve quit success rates, these rates nevertheless remain modest (i.e., 1 year quit rates range between 8% and 23%; CADTH, 2014; Lancaster & Stead, 2017). Hence, there is a need to explore alternative and/or adjunct treatment options that may help to improve existing smoking cessation treatment and maintenance approaches.
55.2 WHY EXERCISE MIGHT BE AN EFFECTIVE SMOKING CESSATION TREATMENT OPTION Evidence from a number of large cross-sectional surveys indicates that levels of physical activity (PA) are inversely related to smoking rates (Picavet, Wendelvos, Vreeken, Schuit, & Verschuren, 2011). Additionally, greater levels of PA have been positively associated with initiating a quit attempt (Gauthier, Snelling, & King, 2012), confidence in maintaining smoking abstinence (King, Marcus, Pinto, Emmons, & Abrams, 1996), and successful smoking cessation (Abrantes et al., 2009). Evidences from two metaanalyses have shown that an acute bout of exercise reduces the magnitude of urges to smoke following a temporary period of abstinence compared with control conditions (Haasova et al., 2013; Roberts, Maddison, Simpson, Bullen, & Prapavessis, 2012). Numerous nicotine withdrawal symptoms during the cessation process have also been shown to be ameliorated by exercise (Ussher, Taylor, & Faulkner, 2014). In addition, there is research evidence, which indicates exercise may reduce postcessation weight gain in the long term (Farley, Hajek, Lycett, & Aveyard, 2012). Finally, exercise has been shown to have a positive effect on other factors
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health benefits. Hence, it is likely that targeting exercise and smoking cessation in combination may maximize health benefits in smokers.
55.3 EXERCISE AS A SMOKING CESSATION AID
FIG. 55.1 Nicotine gum. An illustration of a common form of nicotine replacement therapy (NRT). Figure unpublished.
that may protect against smoking relapse, including depression (Williams, 2008), general fatigue and sleep disturbances (Hatsukami, Hughes, Pickens, & Suilis, 1984), self-esteem (Spence, McGannon, & Poon, 2005), and perceived coping ability (Tritter, Fitzgeorge, & Prapavessis, 2015). Taken together, there is evidence supporting the benefits of exercise as a component of tobacco dependence treatments. It should be highlighted that being physically active is associated with numerous
FIG. 55.2 A transdermal nicotine patch. An illustration of a common form of NRT. Figure unpublished.
A number of studies have examined the influence of exercise, either alone or in combination with traditional smoking cessation approaches (i.e., behavioral therapy and/or pharmacotherapy) on smoking cessation outcomes. When commenting on the trials to date, continuous abstinence will be reported as the primary outcome measure over 7-day point prevalence abstinence when both are reported. This can be justified as continuous abstinence is a more stringent measure of smoking cessation and relates more directly to health outcomes (Marcus et al., 1999). Cochrane review. Ussher et al. (2014) conducted a systematic review to determine whether exercise-based interventions alone or combined with a smoking cessation program are more effective than a smoking cessation intervention alone. In this review, 20 randomized controlled trials (RCTs; n ¼ 5870) examining exercise-aided interventions for smoking cessation with at least a 6-month follow-up period were identified. Only 4 of the 20 trials showed significantly higher abstinence rates in the exercise-aided group versus a control group at the end of treatment (Bock et al., 2012; Marcus et al., 1999; Marcus, Albrecht, Niaura, Abrams, & Thompson, 1991; Martin et al., 1997), while only one study showed a borderline significant benefit of exercise at 1-year follow-up (Marcus et al., 1999—see Fig. 55.3). In addition, only four
55.3 EXERCISE AS A SMOKING CESSATION AID
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FIG. 55.3 Continuous abstinence rates by treatment condition at the end of treatment and 3 and 12 months following quit day. Bars denote abstinence rates (%) for the exercise-aided group versus control group at postquit day follow-ups. Asterisk indicates significance (P < .05). Adapted from data by Marcus et al. (1999); figure unpublished.
studies examined the effectiveness of combining exercise with NRT (Hill, Rigdon, & Johnson, 1993; Kinnunen et al., 2008; Martin et al., 1997; Prapavessis et al., 2007). Of these, one study showed significantly higher abstinence rates in the exercise-plus-patch group compared to the exercise-only group at the end of treatment and at 12-month follow-up (Prapavessis et al., 2007). A number of explanations can be offered to explain the lack of findings among the majority of studies. First, only one study was found to be at low risk of bias across all domains, and only seven studies had a sufficiently large sample size to detect a significant difference between treatment and control conditions. Second, studies were found to vary in the timing and intensity of the smoking cessation and exercise programs offered. Third, cessation outcomes varied across studies as continuous abstinence was assessed in eight, prolonged abstinence in two, and point prevalence abstinence in eight; two did not specify. Fourth, many trials included interventions, which may not have been of sufficient intensity to produce the required changes in exercise levels. In conclusion, this review provided evidence warranting further investigation into the role of exercise as a smoking cessation aid. In the following pages, the reader is provided with detailed insight into the “state of affairs” of the exercise-aided smoking cessation literature that has been published since the Ussher et al. (2014) Cochrane review. Intensive exercise-aided treatment. Abrantes et al. (2014) argued that a number of methodological limitations (e.g., insufficient intervention intensity, lack of efforts to increase adherence, and lack of contact control conditions) inherent in previous exercise intervention trials might have served to diminish its effectiveness as a smoking cessation aid. To address these limitations, Abrantes and colleagues conducted a 12-week RCT to examine the effectiveness of a behavioral exercise intervention for smokers (n ¼ 61). Participants in the aerobic exercise (AE) condition received supervised exercise
sessions (once per week; see Fig. 55.4), prescriptions to engage in home-based moderate-intensity exercise (2–4 times per week), weekly, cognitive behavioral group counseling sessions for exercise promotion, and a financial incentive component based on treatment compliance. Participants in the health education contact control (HEC) were asked to attend weekly hour-long health education sessions. Independent of condition, all participants received an 8-week (beginning week 5) smoking
FIG. 55.4 Supervised exercise session for smoking cessation. This figure illustrates an example of an on-site structured aerobic exercise session during an exercise-aided cessation program. Figure unpublished.
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Biochemically verified continuous abstinence was assessed between the quit date and end of pregnancy. Findings indicated there were no significant differences in rates of smoking abstinence between groups at the end of pregnancy. Continuous abstinence rates were 8% and 6% in the PA and control groups, respectively (OR 1.21, 95% CI: 0.70–2.10). However, compared to the control group, increases in self-reported minutes of weekly PA were significantly greater for the PA group by 33% (95% CI: 14%–56%), 28% (95% CI: 7%–52%), and 36% (95% CI: 12%–65%) at 1, 4, and 6 weeks postquit day, respectively. These findings indicate that a PA intervention, in conjunction with behavioral cessation support, does not significantly increase cessation rates in pregnant smokers compared to behavioral support alone. Despite low attendance in the PA group (only 29% adherence), the PA consultation component may have still served to increase PA levels. The authors suggested that perhaps being asked to change two health behaviors simultaneously (i.e., smoking and PA) while also dealing with pregnancy was too difficult a task. Future interventions for smoking cessation during pregnancy should initiate exercise well before the anticipated quit date in order to ease the load on those attempting to quit and maximize the potential for exercise to assist smoking cessation. Economically disadvantaged smokers who are not intending to stop smoking may benefit from treatments aimed at reducing their smoking. Using a pilot RCT, Thompson et al. (2016) assessed the effects of an exercise-assisted reduction then stop-smoking intervention on smoking and PA outcomes at 16 weeks compared with usual care. Disadvantaged smokers (n ¼ 99) who wished to reduce their smoking but not quit were randomized to receive usual care or usual care plus the exercise-assisted reduction then stop-smoking intervention. The intervention consisted of up to 12 weekly client-centered individual motivational support sessions to promote smoking reduction and increased PA. Compared with controls, participants in the intervention group were more likely to make a quit attempt (35.5% vs 9.7%, respectively; OR 5.05, 95% CI: 1.10–23.15), and a greater proportion achieved at least a 50% reduction in cigarettes smoked at 16 weeks (63.3% vs 32.3%, respectively; OR 4.21, 95% CI: 1.32–13.39). Furthermore, promising differences between groups were found for postquit abstinence at 4-week follow-up (23% vs 6%; OR 4.91, 95% CI: 0.80–30.24). Unfortunately, no intervention effect on PA was found, and the percentage of support sessions attended (52.5%) could have been greater among intervention smokers. This study was one of the first to examine the effectiveness of a behavioral intervention focusing FIG. 55.5 Continuous abstinence rates by treatment condition at the end on PA to promote smoking reduction among smokers who initially did not want to quit. The findings suggest of treatment and 6 and 12 months following quit day. Bars indicate abstinence rates (%) for the aerobic exercise condition versus that an exercise-assisted smoking reduction intervention health education contact control condition. Adapted from data by Abrantes with behavioral counseling appears to be more effective et al. (2014); figure unpublished. than usual care alone in achieving reduction. cessation protocol including 20 min weekly telephone counseling sessions and NRT treatment (i.e., transdermal patch). Assessments were administered at baseline, 3(end of treatment), 6-, and 12-month follow-ups. Treatment adherence in both groups was fairly high (i.e., 75%). Participants in the AE condition demonstrated higher continuous abstinence rates (EOT: 30% vs 25.8%, OR 1.23; 6-month follow-up: 23.3% vs 9.7%, OR 2.83; 12-month follow-up: 13.3% vs 3.2%, OR 4.64) compared to those in the HEC condition; however, these differences did not reach statistical significance (see Fig. 55.5). It was also found that participants in the AE condition reported significantly higher levels of PA following quit day (b ¼ 1.37, SE ¼ 0.43, P < .01). This intervention included a number of notable features to promote exercise adherence including supervised moderate-intensity aerobic exercise sessions, a sequential approach with exercise initiation preceding the quit date by 1 month, combined supervised plus home-based exercise, a contingencybased financial incentive component, and cognitive behavioral exercise counseling. In conclusion, this preliminary trial provided promising evidence that a behavioral exercise intervention may be a useful adjunct to improve cessation outcomes over standard care alone. Special populations. Exercise as a smoking cessation aid has also been investigated in particular at-risk populations. For example, Ussher et al. (2015) implemented a large-scale, multicenter RCT to determine the effectiveness of a PA intervention as a smoking cessation aid for pregnant smokers (n ¼ 789). Participants were randomized to receive 6 weekly sessions of individual behavioral cessation support alone (control) or behavioral cessation support plus a PA intervention, which included PA consultations and 14 sessions of supervised moderate-intensity exercise over 8 weeks (2 times per week for weeks 1–6 and once per week for weeks 6–8). Interventions began 1 week before the target quit date.
55.3 EXERCISE AS A SMOKING CESSATION AID
In a recent study, Smits et al. (2016) conducted an RCT to examine the effectiveness of vigorous-intensity exercise as an aid to smoking cessation among sedentary adult daily smokers with high anxiety sensitivity. All participants (n ¼ 136) received 15 weeks of standard smoking cessation treatment (ST; i.e., 7 weekly cognitive behavioral therapy sessions plus NRT patches starting at week 6) and were asked to make a quit attempt at week 6. In addition, participants were randomly assigned to either a 15-week supervised exercise program (ST + EX) or 15-week wellness education contact control condition (ST + CTRL), each consisting of three 35 min sessions per week. Assessments were administered at 10 (end of treatment), 16 (i.e., 4 months), and 24 weeks (i.e., 6 months) after the target quit date. Results showed adherence to be mediocre with participants attending an average of 24 of the 45 (i.e., 53%) total exercise or wellness education treatment sessions. With regard to smoking abstinence, findings indicated that continuous abstinence rates were significantly higher for those in the ST + EX condition than for those in the ST + CTRL condition at each assessment period among those with high anxiety sensitivity (continuous abstinence: b ¼ 0.98, SE ¼ 0.346, t(132) ¼ 2.84, and P ¼ .005), but not among those with low anxiety sensitivity. Among those with high anxiety sensitivity, estimated continuous abstinence rates at the end of treatment, 4 months postquit day, and 6 months postquit day were 25.9% versus 11.6%, 24.8% versus 11.0%, and 23.3% versus 10.2% for the ST + EX versus ST + CTRL conditions, respectively. Hence, among adult smokers with high levels of anxiety sensitivity, combining exercise with standard care may increase the odds of quit success compared to standard care alone. Exercise and cessation maintenance. Prapavessis et al. (2016) conducted the “Getting Physical on Cigarettes” RCT to examine the effectiveness of an exercise-aided NRT smoking cessation intervention
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program, with built-in exercise and smoking cessation maintenance components, on postintervention 14-, 26-, and 56-week continuous smoking abstinence. Acknowledging the importance of adherence to the success of exercise-aided cessation programs, Prapavessis and colleagues also sought to determine whether adherence throughout the program had an influence on smoking status. Female cigarette smokers (n ¼ 413) who wished to quit smoking were recruited to participate in a 14-week supervised exercise and NRT (i.e., transdermal patch) smoking cessation program and were subsequently randomized to one of four conditions: exercise maintenance plus smoking cessation maintenance, exercise maintenance plus contact control, smoking cessation maintenance plus contact control, or contact control. A targeted quit date was set for week 4. Those in the exercise maintenance groups received five group-based CBT sessions to promote exercise adherence during weeks 8–14 and telephone counseling to maintain exercise behavior during weeks 26 and 52. Those in the smoking cessation plus contact control and contact control arms received five health education sessions during weeks 8–14 and telephone counseling regarding women’s health issues during weeks 26 and 52. At week 14, the smoking cessation maintenance groups received informational booklets targeting cessation and relapse prevention. Adherence rates for the supervised exercise sessions (66%), NRT protocol (68.81%), and CBT exercise maintenance component (54%) were substantially higher than adherence to the postintervention telephone exercise maintenance component (38%). It was found that abstainers had higher treatment adherence rates and received more maintenance than their smoking counterparts. Differences in continuous smoking abstinence rates between the exercise and equal contact nonexercise maintenance groups were found at weeks 14 (57% vs 43%), 26 (27% vs 21%), and 56 (26% vs 23.5%) (see Fig. 55.6). FIG. 55.6 Continuous abstinence rates by treatment condition at the end of treatment and 26- and 56-week follow-ups. Bars indicate abstinence rates (%) for the exercise maintenance groups versus equal contact nonexercise maintenance groups. Adapted from data by Prapavessis et al. (2016); figure unpublished.
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Despite these clinically meaningful differences, only the week-14 differences in smoking status approached significance (χ 2 [1, n ¼ 409] ¼ 2.36, and P ¼ .08). These findings suggest that other methods of delivering exercise maintenance following termination of an exercise-aided NRT smoking cessation program need to be considered.
55.4 FUTURE DIRECTIONS A number of future recommendations can be made concerning the role of exercise as a smoking cessation aid. Trials with larger sample sizes, structured on-site exercise interventions with at least moderate exercise intensity, equal contact control conditions, biochemically verified continuous smoking abstinence as the primary outcome, and follow-up periods of at least 6 months are needed to ascertain the effects of exercise for smoking cessation. With regard to intervention design, it has been argued that being asked to change two health behaviors simultaneously may be too difficult to achieve (e.g., Prapavessis et al., 2007, 2016; Ussher et al., 2015). Hence, it is recommended that the exercise program begin at a time prior to the smoker initiating a quit attempt, thereby allowing individuals to focus on becoming more active before being asked to significantly change their smoking behavior (Ussher et al., 2014). Based on the findings reported herein, it is also recommended that future trials include pharmacological or behavioral therapies as the foundation in smoking cessation treatment. Evidence suggests that a combined approach incorporating exercise with NRT or behavioral counseling may improve abstinence rates and increase the likelihood of a successful quit attempt over either treatment option alone. A key focus for future research is to find novel and innovative approaches to maximize adherence to these cessation programs. One possible solution to improve adherence rates to exercise-aided smoking cessation programs that was addressed in the study by Prapavessis et al. (2016) is to focus on the maintenance stage of both exercise and smoking cessation. All smoking cessation programs (including exercise-aided ones) have shown early promise followed by relapse effects at the end of treatment and follow-up. Hence, it is vital that these types of programs integrate both initial cessation and exercise maintenance components into their design to prevent relapse in both behaviors. To date, programs that have weaned smokers off supervised exercise sessions have not succeeded in promoting independent exercise among participants following program termination. Future work is required to investigate more effective ways to sustain both long-term smoking abstinence and exercise. It is possible that face-to-face technology and applications with real-time feedback may provide viable options to improve exercise maintenance and reduce smoking
relapse (Free et al., 2011). In order to accurately assess treatment adherence, it is recommended that future research include objective measures of exercise adherence over treatment and follow-up. Further research is also needed to test different forms of exercise prescription and to determine the most effective timing, intensity, and modalities of exercise. The design and implementation of exercise-aided cessation programs in real-world settings are also warranted to allow for future dissemination of this approach as a cessation aid. Finally, additional research is needed to investigate the role of exercise for smoking cessation among more ethnically diverse populations, at-risk populations (e.g., cardiovascular disease patients), and different age groups (e.g., youth smokers).
55.5 CONCLUSION Exercise and smoking cessation are both independently beneficial for health. Thus, combining exercise with existing smoking cessation treatment options could prove to be the best approach to promote and sustain smoking abstinence. Based on the findings to date, there is some research evidence to support the effectiveness of exercise as an adjunct to behavioral counseling and pharmacotherapy (i.e., NRT) treatment options in smoking cessation. Evidence suggests that exercise has the potential to improve rates of continuous abstinence over and above traditional smoking cessation treatments alone; however, exercise adherence is a consistent problem, particularly after program termination. This is unfortunate as there is a clear association between exercise adherence and cessation outcomes. Future trials need to explore ways to improve adherence to exercise treatment and maintain exercise following the termination of exerciseaided cessation programs in order to generate the greatest effects on smoking cessation and health-related outcomes.
MINI-DICTIONARY OF TERMS Aerobic exercise A category of exercise that primarily challenges the cardiorespiratory system. It includes activities such as walking, cycling, running, and swimming. Behavioral counseling A type of therapy that includes motivational support, reinforcement of nonsmoking behavior, relaxation training, coping skills training, contingency management, self-control, and cognitive behavioral therapy. Behavioral therapy approaches vary in both their intensity and delivery format. Continuous abstinence Refers to having smoked no more than five cigarettes since the quit date. Exercise A subcategory of physical activity; planned, structured, and repetitive activity focused on improving or maintaining measures of physical fitness and/or mental health. Purposeful exercise is typically performed at a moderate-vigorous intensity and accumulated in bouts >10 min.
REFERENCES
Moderate-intensity exercise Exercise that requires a moderate amount of effort and noticeably accelerates the heart rate (i.e., 50%–70% of maximal heart rate). Examples include brisk walking, dancing, and bicycling. Nicotine replacement therapy NRT; for example, gum, transdermal patch, inhaler, nasal spray, and lozenge substitute for tobaccoderived nicotine in the blood and reduce nicotine-related craving and withdrawal symptoms in abstaining smokers. Physical activity Any body movement produced by skeletal muscles that results in energy expenditure above resting level. Quit attempt A period of time in which a smoker abstains from smoking cigarettes; defined as a period of at least 24 h of abstinence. Seven-day point prevalence abstinence Defined as not a single puff of a cigarette in the past 7 days. Smoking cessation The process of discontinuing cigarette smoking; typically refers to the point at which a person attains smoking abstinence. Smoking relapse The point that the smoker resumes smoking cigarettes following a quit episode. Vigorous-intensity exercise Exercise that requires a large amount of effort and causes rapid breathing and substantial increase in heart rate (i.e., 70%–85% of maximal heart rate). Examples include running and fast swimming.
Key Facts of Exercise as a Smoking Cessation Aid • An acute bout of exercise reduces nicotine-related craving and withdrawal symptoms during a quit attempt. • Exercise may reduce postcessation weight gain. • Exercise is associated with numerous health benefits. • In industrial countries, only 15% of the adult population engages in regular physical activity. • Early physical activity patterns in life are strongly predictive of physical activity patterns later in life. Summary Points • This chapter focuses on the effectiveness of exercise, either alone or in combination with traditional smoking cessation treatments, as a smoking cessation aid. • Despite the availability of existing treatment options, only 8%–23% of individuals remain successfully tobacco-free 1 year following their quit attempt. • Recently, exercise has been proposed as an aid for smoking cessation because of its demonstrated potential to reduce nicotine-related cravings and withdrawal symptoms. • There is some evidence suggesting that exercise-aided cessation programs have the potential to improve continuous abstinence rates, compared to traditional smoking cessation treatments alone; however, exercise adherence is a consistent problem, particularly after program termination. • Novel and innovative approaches to improve adherence to exercise treatment and maintain exercise following the termination of an exercise-aided cessation program are needed.
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55 Exercise as a Smoking Cessation Aid Scott Rollo, Wuyou Sui, Harry Prapavessis Faculty of Health Sciences, School of Kinesiology, The University of Western Ontario, London, ON, Canada
Abbreviations CBT NRT PA RCT
cognitive behavioral therapy nicotine replacement therapy physical activity randomized controlled trial
55.1 INTRODUCTION Tobacco smoking is the leading cause of preventable deaths worldwide, with over 6 million deaths each year attributable to tobacco use (WHO, 2017). It has been well established that smoking is detrimental to one’s health and an important modifiable risk factor for numerous chronic diseases (USDHHS, 2010). Although it is declining worldwide, the prevalence of tobacco smoking is still over 1.1 billion people globally (WHO, 2017). Smoking cessation at any age is associated with numerous health benefits and diminished risk of developing smokingrelated diseases, such as lung cancer, heart attack, stroke, and chronic lung disease (USDHHS, 1990). Unfortunately, smoking cessation is difficult. Despite the known health consequences, many smokers find it challenging to quit smoking, and failure rates are consistently high. Among adult smokers who quit smoking without formal treatment, only 3%–5% are successfully tobacco-free 1 year following their quit attempt (Hughes, Keely, & Naud, 2004). Low quit rates can be explained by a number of factors including the highly addictive properties of nicotine found within cigarettes (Hirschhorn and World Health Organization, 2009), heightened cravings and withdrawal symptoms (Allen, Bade, Hatsukami, & Center, 2008), weight gain associated with smoking cessation (Klesges et al., 1988), and the learned and reinforcing behavior of smoking (CADTH, 2014). Numerous pharmacological (e.g., nicotine replacement therapies (NRT), nicotine gum, inhaler, nasal spray, transdermal patch, and lozenge; see Figs. 55.1 and 55.2) and behavioral smoking cessation treatment (e.g.,
Neuroscience of Nicotine https://doi.org/10.1016/B978-0-12-813035-3.00055-1
cognitive behavioral therapy (CBT)) options exist to aid in the cessation process, promote cessation maintenance, and prevent smoking relapse (Collins, Witkiewitz, Kirouac, & Marlatt, 2010). While the combination of the abovementioned interventions has shown to improve quit success rates, these rates nevertheless remain modest (i.e., 1 year quit rates range between 8% and 23%; CADTH, 2014; Lancaster & Stead, 2017). Hence, there is a need to explore alternative and/or adjunct treatment options that may help to improve existing smoking cessation treatment and maintenance approaches.
55.2 WHY EXERCISE MIGHT BE AN EFFECTIVE SMOKING CESSATION TREATMENT OPTION Evidence from a number of large cross-sectional surveys indicates that levels of physical activity (PA) are inversely related to smoking rates (Picavet, Wendelvos, Vreeken, Schuit, & Verschuren, 2011). Additionally, greater levels of PA have been positively associated with initiating a quit attempt (Gauthier, Snelling, & King, 2012), confidence in maintaining smoking abstinence (King, Marcus, Pinto, Emmons, & Abrams, 1996), and successful smoking cessation (Abrantes et al., 2009). Evidences from two metaanalyses have shown that an acute bout of exercise reduces the magnitude of urges to smoke following a temporary period of abstinence compared with control conditions (Haasova et al., 2013; Roberts, Maddison, Simpson, Bullen, & Prapavessis, 2012). Numerous nicotine withdrawal symptoms during the cessation process have also been shown to be ameliorated by exercise (Ussher, Taylor, & Faulkner, 2014). In addition, there is research evidence, which indicates exercise may reduce postcessation weight gain in the long term (Farley, Hajek, Lycett, & Aveyard, 2012). Finally, exercise has been shown to have a positive effect on other factors
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health benefits. Hence, it is likely that targeting exercise and smoking cessation in combination may maximize health benefits in smokers.
55.3 EXERCISE AS A SMOKING CESSATION AID
FIG. 55.1 Nicotine gum. An illustration of a common form of nicotine replacement therapy (NRT). Figure unpublished.
that may protect against smoking relapse, including depression (Williams, 2008), general fatigue and sleep disturbances (Hatsukami, Hughes, Pickens, & Suilis, 1984), self-esteem (Spence, McGannon, & Poon, 2005), and perceived coping ability (Tritter, Fitzgeorge, & Prapavessis, 2015). Taken together, there is evidence supporting the benefits of exercise as a component of tobacco dependence treatments. It should be highlighted that being physically active is associated with numerous
FIG. 55.2 A transdermal nicotine patch. An illustration of a common form of NRT. Figure unpublished.
A number of studies have examined the influence of exercise, either alone or in combination with traditional smoking cessation approaches (i.e., behavioral therapy and/or pharmacotherapy) on smoking cessation outcomes. When commenting on the trials to date, continuous abstinence will be reported as the primary outcome measure over 7-day point prevalence abstinence when both are reported. This can be justified as continuous abstinence is a more stringent measure of smoking cessation and relates more directly to health outcomes (Marcus et al., 1999). Cochrane review. Ussher et al. (2014) conducted a systematic review to determine whether exercise-based interventions alone or combined with a smoking cessation program are more effective than a smoking cessation intervention alone. In this review, 20 randomized controlled trials (RCTs; n ¼ 5870) examining exercise-aided interventions for smoking cessation with at least a 6-month follow-up period were identified. Only 4 of the 20 trials showed significantly higher abstinence rates in the exercise-aided group versus a control group at the end of treatment (Bock et al., 2012; Marcus et al., 1999; Marcus, Albrecht, Niaura, Abrams, & Thompson, 1991; Martin et al., 1997), while only one study showed a borderline significant benefit of exercise at 1-year follow-up (Marcus et al., 1999—see Fig. 55.3). In addition, only four
55.3 EXERCISE AS A SMOKING CESSATION AID
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FIG. 55.3 Continuous abstinence rates by treatment condition at the end of treatment and 3 and 12 months following quit day. Bars denote abstinence rates (%) for the exercise-aided group versus control group at postquit day follow-ups. Asterisk indicates significance (P < .05). Adapted from data by Marcus et al. (1999); figure unpublished.
studies examined the effectiveness of combining exercise with NRT (Hill, Rigdon, & Johnson, 1993; Kinnunen et al., 2008; Martin et al., 1997; Prapavessis et al., 2007). Of these, one study showed significantly higher abstinence rates in the exercise-plus-patch group compared to the exercise-only group at the end of treatment and at 12-month follow-up (Prapavessis et al., 2007). A number of explanations can be offered to explain the lack of findings among the majority of studies. First, only one study was found to be at low risk of bias across all domains, and only seven studies had a sufficiently large sample size to detect a significant difference between treatment and control conditions. Second, studies were found to vary in the timing and intensity of the smoking cessation and exercise programs offered. Third, cessation outcomes varied across studies as continuous abstinence was assessed in eight, prolonged abstinence in two, and point prevalence abstinence in eight; two did not specify. Fourth, many trials included interventions, which may not have been of sufficient intensity to produce the required changes in exercise levels. In conclusion, this review provided evidence warranting further investigation into the role of exercise as a smoking cessation aid. In the following pages, the reader is provided with detailed insight into the “state of affairs” of the exercise-aided smoking cessation literature that has been published since the Ussher et al. (2014) Cochrane review. Intensive exercise-aided treatment. Abrantes et al. (2014) argued that a number of methodological limitations (e.g., insufficient intervention intensity, lack of efforts to increase adherence, and lack of contact control conditions) inherent in previous exercise intervention trials might have served to diminish its effectiveness as a smoking cessation aid. To address these limitations, Abrantes and colleagues conducted a 12-week RCT to examine the effectiveness of a behavioral exercise intervention for smokers (n ¼ 61). Participants in the aerobic exercise (AE) condition received supervised exercise
sessions (once per week; see Fig. 55.4), prescriptions to engage in home-based moderate-intensity exercise (2–4 times per week), weekly, cognitive behavioral group counseling sessions for exercise promotion, and a financial incentive component based on treatment compliance. Participants in the health education contact control (HEC) were asked to attend weekly hour-long health education sessions. Independent of condition, all participants received an 8-week (beginning week 5) smoking
FIG. 55.4 Supervised exercise session for smoking cessation. This figure illustrates an example of an on-site structured aerobic exercise session during an exercise-aided cessation program. Figure unpublished.
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Biochemically verified continuous abstinence was assessed between the quit date and end of pregnancy. Findings indicated there were no significant differences in rates of smoking abstinence between groups at the end of pregnancy. Continuous abstinence rates were 8% and 6% in the PA and control groups, respectively (OR 1.21, 95% CI: 0.70–2.10). However, compared to the control group, increases in self-reported minutes of weekly PA were significantly greater for the PA group by 33% (95% CI: 14%–56%), 28% (95% CI: 7%–52%), and 36% (95% CI: 12%–65%) at 1, 4, and 6 weeks postquit day, respectively. These findings indicate that a PA intervention, in conjunction with behavioral cessation support, does not significantly increase cessation rates in pregnant smokers compared to behavioral support alone. Despite low attendance in the PA group (only 29% adherence), the PA consultation component may have still served to increase PA levels. The authors suggested that perhaps being asked to change two health behaviors simultaneously (i.e., smoking and PA) while also dealing with pregnancy was too difficult a task. Future interventions for smoking cessation during pregnancy should initiate exercise well before the anticipated quit date in order to ease the load on those attempting to quit and maximize the potential for exercise to assist smoking cessation. Economically disadvantaged smokers who are not intending to stop smoking may benefit from treatments aimed at reducing their smoking. Using a pilot RCT, Thompson et al. (2016) assessed the effects of an exercise-assisted reduction then stop-smoking intervention on smoking and PA outcomes at 16 weeks compared with usual care. Disadvantaged smokers (n ¼ 99) who wished to reduce their smoking but not quit were randomized to receive usual care or usual care plus the exercise-assisted reduction then stop-smoking intervention. The intervention consisted of up to 12 weekly client-centered individual motivational support sessions to promote smoking reduction and increased PA. Compared with controls, participants in the intervention group were more likely to make a quit attempt (35.5% vs 9.7%, respectively; OR 5.05, 95% CI: 1.10–23.15), and a greater proportion achieved at least a 50% reduction in cigarettes smoked at 16 weeks (63.3% vs 32.3%, respectively; OR 4.21, 95% CI: 1.32–13.39). Furthermore, promising differences between groups were found for postquit abstinence at 4-week follow-up (23% vs 6%; OR 4.91, 95% CI: 0.80–30.24). Unfortunately, no intervention effect on PA was found, and the percentage of support sessions attended (52.5%) could have been greater among intervention smokers. This study was one of the first to examine the effectiveness of a behavioral intervention focusing FIG. 55.5 Continuous abstinence rates by treatment condition at the end on PA to promote smoking reduction among smokers who initially did not want to quit. The findings suggest of treatment and 6 and 12 months following quit day. Bars indicate abstinence rates (%) for the aerobic exercise condition versus that an exercise-assisted smoking reduction intervention health education contact control condition. Adapted from data by Abrantes with behavioral counseling appears to be more effective et al. (2014); figure unpublished. than usual care alone in achieving reduction. cessation protocol including 20 min weekly telephone counseling sessions and NRT treatment (i.e., transdermal patch). Assessments were administered at baseline, 3(end of treatment), 6-, and 12-month follow-ups. Treatment adherence in both groups was fairly high (i.e., 75%). Participants in the AE condition demonstrated higher continuous abstinence rates (EOT: 30% vs 25.8%, OR 1.23; 6-month follow-up: 23.3% vs 9.7%, OR 2.83; 12-month follow-up: 13.3% vs 3.2%, OR 4.64) compared to those in the HEC condition; however, these differences did not reach statistical significance (see Fig. 55.5). It was also found that participants in the AE condition reported significantly higher levels of PA following quit day (b ¼ 1.37, SE ¼ 0.43, P < .01). This intervention included a number of notable features to promote exercise adherence including supervised moderate-intensity aerobic exercise sessions, a sequential approach with exercise initiation preceding the quit date by 1 month, combined supervised plus home-based exercise, a contingencybased financial incentive component, and cognitive behavioral exercise counseling. In conclusion, this preliminary trial provided promising evidence that a behavioral exercise intervention may be a useful adjunct to improve cessation outcomes over standard care alone. Special populations. Exercise as a smoking cessation aid has also been investigated in particular at-risk populations. For example, Ussher et al. (2015) implemented a large-scale, multicenter RCT to determine the effectiveness of a PA intervention as a smoking cessation aid for pregnant smokers (n ¼ 789). Participants were randomized to receive 6 weekly sessions of individual behavioral cessation support alone (control) or behavioral cessation support plus a PA intervention, which included PA consultations and 14 sessions of supervised moderate-intensity exercise over 8 weeks (2 times per week for weeks 1–6 and once per week for weeks 6–8). Interventions began 1 week before the target quit date.
55.3 EXERCISE AS A SMOKING CESSATION AID
In a recent study, Smits et al. (2016) conducted an RCT to examine the effectiveness of vigorous-intensity exercise as an aid to smoking cessation among sedentary adult daily smokers with high anxiety sensitivity. All participants (n ¼ 136) received 15 weeks of standard smoking cessation treatment (ST; i.e., 7 weekly cognitive behavioral therapy sessions plus NRT patches starting at week 6) and were asked to make a quit attempt at week 6. In addition, participants were randomly assigned to either a 15-week supervised exercise program (ST + EX) or 15-week wellness education contact control condition (ST + CTRL), each consisting of three 35 min sessions per week. Assessments were administered at 10 (end of treatment), 16 (i.e., 4 months), and 24 weeks (i.e., 6 months) after the target quit date. Results showed adherence to be mediocre with participants attending an average of 24 of the 45 (i.e., 53%) total exercise or wellness education treatment sessions. With regard to smoking abstinence, findings indicated that continuous abstinence rates were significantly higher for those in the ST + EX condition than for those in the ST + CTRL condition at each assessment period among those with high anxiety sensitivity (continuous abstinence: b ¼ 0.98, SE ¼ 0.346, t(132) ¼ 2.84, and P ¼ .005), but not among those with low anxiety sensitivity. Among those with high anxiety sensitivity, estimated continuous abstinence rates at the end of treatment, 4 months postquit day, and 6 months postquit day were 25.9% versus 11.6%, 24.8% versus 11.0%, and 23.3% versus 10.2% for the ST + EX versus ST + CTRL conditions, respectively. Hence, among adult smokers with high levels of anxiety sensitivity, combining exercise with standard care may increase the odds of quit success compared to standard care alone. Exercise and cessation maintenance. Prapavessis et al. (2016) conducted the “Getting Physical on Cigarettes” RCT to examine the effectiveness of an exercise-aided NRT smoking cessation intervention
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program, with built-in exercise and smoking cessation maintenance components, on postintervention 14-, 26-, and 56-week continuous smoking abstinence. Acknowledging the importance of adherence to the success of exercise-aided cessation programs, Prapavessis and colleagues also sought to determine whether adherence throughout the program had an influence on smoking status. Female cigarette smokers (n ¼ 413) who wished to quit smoking were recruited to participate in a 14-week supervised exercise and NRT (i.e., transdermal patch) smoking cessation program and were subsequently randomized to one of four conditions: exercise maintenance plus smoking cessation maintenance, exercise maintenance plus contact control, smoking cessation maintenance plus contact control, or contact control. A targeted quit date was set for week 4. Those in the exercise maintenance groups received five group-based CBT sessions to promote exercise adherence during weeks 8–14 and telephone counseling to maintain exercise behavior during weeks 26 and 52. Those in the smoking cessation plus contact control and contact control arms received five health education sessions during weeks 8–14 and telephone counseling regarding women’s health issues during weeks 26 and 52. At week 14, the smoking cessation maintenance groups received informational booklets targeting cessation and relapse prevention. Adherence rates for the supervised exercise sessions (66%), NRT protocol (68.81%), and CBT exercise maintenance component (54%) were substantially higher than adherence to the postintervention telephone exercise maintenance component (38%). It was found that abstainers had higher treatment adherence rates and received more maintenance than their smoking counterparts. Differences in continuous smoking abstinence rates between the exercise and equal contact nonexercise maintenance groups were found at weeks 14 (57% vs 43%), 26 (27% vs 21%), and 56 (26% vs 23.5%) (see Fig. 55.6). FIG. 55.6 Continuous abstinence rates by treatment condition at the end of treatment and 26- and 56-week follow-ups. Bars indicate abstinence rates (%) for the exercise maintenance groups versus equal contact nonexercise maintenance groups. Adapted from data by Prapavessis et al. (2016); figure unpublished.
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Despite these clinically meaningful differences, only the week-14 differences in smoking status approached significance (χ 2 [1, n ¼ 409] ¼ 2.36, and P ¼ .08). These findings suggest that other methods of delivering exercise maintenance following termination of an exercise-aided NRT smoking cessation program need to be considered.
55.4 FUTURE DIRECTIONS A number of future recommendations can be made concerning the role of exercise as a smoking cessation aid. Trials with larger sample sizes, structured on-site exercise interventions with at least moderate exercise intensity, equal contact control conditions, biochemically verified continuous smoking abstinence as the primary outcome, and follow-up periods of at least 6 months are needed to ascertain the effects of exercise for smoking cessation. With regard to intervention design, it has been argued that being asked to change two health behaviors simultaneously may be too difficult to achieve (e.g., Prapavessis et al., 2007, 2016; Ussher et al., 2015). Hence, it is recommended that the exercise program begin at a time prior to the smoker initiating a quit attempt, thereby allowing individuals to focus on becoming more active before being asked to significantly change their smoking behavior (Ussher et al., 2014). Based on the findings reported herein, it is also recommended that future trials include pharmacological or behavioral therapies as the foundation in smoking cessation treatment. Evidence suggests that a combined approach incorporating exercise with NRT or behavioral counseling may improve abstinence rates and increase the likelihood of a successful quit attempt over either treatment option alone. A key focus for future research is to find novel and innovative approaches to maximize adherence to these cessation programs. One possible solution to improve adherence rates to exercise-aided smoking cessation programs that was addressed in the study by Prapavessis et al. (2016) is to focus on the maintenance stage of both exercise and smoking cessation. All smoking cessation programs (including exercise-aided ones) have shown early promise followed by relapse effects at the end of treatment and follow-up. Hence, it is vital that these types of programs integrate both initial cessation and exercise maintenance components into their design to prevent relapse in both behaviors. To date, programs that have weaned smokers off supervised exercise sessions have not succeeded in promoting independent exercise among participants following program termination. Future work is required to investigate more effective ways to sustain both long-term smoking abstinence and exercise. It is possible that face-to-face technology and applications with real-time feedback may provide viable options to improve exercise maintenance and reduce smoking
relapse (Free et al., 2011). In order to accurately assess treatment adherence, it is recommended that future research include objective measures of exercise adherence over treatment and follow-up. Further research is also needed to test different forms of exercise prescription and to determine the most effective timing, intensity, and modalities of exercise. The design and implementation of exercise-aided cessation programs in real-world settings are also warranted to allow for future dissemination of this approach as a cessation aid. Finally, additional research is needed to investigate the role of exercise for smoking cessation among more ethnically diverse populations, at-risk populations (e.g., cardiovascular disease patients), and different age groups (e.g., youth smokers).
55.5 CONCLUSION Exercise and smoking cessation are both independently beneficial for health. Thus, combining exercise with existing smoking cessation treatment options could prove to be the best approach to promote and sustain smoking abstinence. Based on the findings to date, there is some research evidence to support the effectiveness of exercise as an adjunct to behavioral counseling and pharmacotherapy (i.e., NRT) treatment options in smoking cessation. Evidence suggests that exercise has the potential to improve rates of continuous abstinence over and above traditional smoking cessation treatments alone; however, exercise adherence is a consistent problem, particularly after program termination. This is unfortunate as there is a clear association between exercise adherence and cessation outcomes. Future trials need to explore ways to improve adherence to exercise treatment and maintain exercise following the termination of exerciseaided cessation programs in order to generate the greatest effects on smoking cessation and health-related outcomes.
MINI-DICTIONARY OF TERMS Aerobic exercise A category of exercise that primarily challenges the cardiorespiratory system. It includes activities such as walking, cycling, running, and swimming. Behavioral counseling A type of therapy that includes motivational support, reinforcement of nonsmoking behavior, relaxation training, coping skills training, contingency management, self-control, and cognitive behavioral therapy. Behavioral therapy approaches vary in both their intensity and delivery format. Continuous abstinence Refers to having smoked no more than five cigarettes since the quit date. Exercise A subcategory of physical activity; planned, structured, and repetitive activity focused on improving or maintaining measures of physical fitness and/or mental health. Purposeful exercise is typically performed at a moderate-vigorous intensity and accumulated in bouts >10 min.
REFERENCES
Moderate-intensity exercise Exercise that requires a moderate amount of effort and noticeably accelerates the heart rate (i.e., 50%–70% of maximal heart rate). Examples include brisk walking, dancing, and bicycling. Nicotine replacement therapy NRT; for example, gum, transdermal patch, inhaler, nasal spray, and lozenge substitute for tobaccoderived nicotine in the blood and reduce nicotine-related craving and withdrawal symptoms in abstaining smokers. Physical activity Any body movement produced by skeletal muscles that results in energy expenditure above resting level. Quit attempt A period of time in which a smoker abstains from smoking cigarettes; defined as a period of at least 24 h of abstinence. Seven-day point prevalence abstinence Defined as not a single puff of a cigarette in the past 7 days. Smoking cessation The process of discontinuing cigarette smoking; typically refers to the point at which a person attains smoking abstinence. Smoking relapse The point that the smoker resumes smoking cigarettes following a quit episode. Vigorous-intensity exercise Exercise that requires a large amount of effort and causes rapid breathing and substantial increase in heart rate (i.e., 70%–85% of maximal heart rate). Examples include running and fast swimming.
Key Facts of Exercise as a Smoking Cessation Aid • An acute bout of exercise reduces nicotine-related craving and withdrawal symptoms during a quit attempt. • Exercise may reduce postcessation weight gain. • Exercise is associated with numerous health benefits. • In industrial countries, only 15% of the adult population engages in regular physical activity. • Early physical activity patterns in life are strongly predictive of physical activity patterns later in life. Summary Points • This chapter focuses on the effectiveness of exercise, either alone or in combination with traditional smoking cessation treatments, as a smoking cessation aid. • Despite the availability of existing treatment options, only 8%–23% of individuals remain successfully tobacco-free 1 year following their quit attempt. • Recently, exercise has been proposed as an aid for smoking cessation because of its demonstrated potential to reduce nicotine-related cravings and withdrawal symptoms. • There is some evidence suggesting that exercise-aided cessation programs have the potential to improve continuous abstinence rates, compared to traditional smoking cessation treatments alone; however, exercise adherence is a consistent problem, particularly after program termination. • Novel and innovative approaches to improve adherence to exercise treatment and maintain exercise following the termination of an exercise-aided cessation program are needed.
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