REVIEW The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect, and smoking behaviour: systematic review update and meta-analysis Vaughan Roberts & Ralph Maddison & Caroline Simpson & Chris Bullen & Harry Prapavessis Received: 9 October 2011 / Accepted: 23 April 2012 / Published online: 15 May 2012 # Springer-Verlag 2012 Abstract Rationale Smoking cessation is associated with cigarette cravings and tobacco withdrawal symptoms (TWS), and exercise appears to ameliorate many of these negative effects. A number of studies have examined the relation- ships between exercise, cigarette cravings, and TWS. Objectives The objectives of this study were (a) to review and update the literature examining the effects of short bouts of exercise on cigarette cravings, TWS, affect, and smoking behaviour and (b) to conduct meta-analyses of the effect of exercise on cigarette cravings. Methods A systematic review of all studies published between January 2006 and June 2011 was conducted. Results Fifteen new studies were identified, 12 of which found a positive effect of exercise on cigarette cravings. The magnitude of statistically significant effect sizes for ‘desire to smoke’ and ‘strength of desire to smoke’ ranged from 0.4 to 1.98 in favour of exercise compared to passive control conditions, and peaked either during or soon after treatment. Effects were found up to 30 min post-exercise. Cigarette cravings were reduced following exercise with a wide range of intensities from isometric exercise and yoga to activity as high as 80–85 % heart rate reserve. Meta- analyses revealed weighted mean differences of −1.90 and −2.41 in ‘desire to smoke’ and ‘strength of desire to smoke’ outcomes, respectively. Measures of TWS and negative affect were reduced following light–moderate intensity exercise, but increased during vigorous exercise. Conclusions Exercise can have a positive effect on cigarette cravings and TWS. However, the most effective exercise intensity to reduce cravings and the underlying mechanisms associated with this effect remain unclear. Keywords Nicotine . Exercise . Physical activity . Smoking cessation . Affect . Smoking topography . Tobacco withdrawal symptoms . Cigarette cravings . Behavioural intervention Background Smoking cessation is associated with tobacco withdrawal symptoms (TWS) such as sleep disturbance, irritability, poor concentration, and depressed mood, as well as intense crav- ing for a cigarette (Hughes 2007). Craving, the presence of withdrawal symptoms, and weight gain are associated with an increased risk of smoking relapse and impact negatively on attempts to quit (West et al. 1989; Borrelli et al. 2001). Therefore, identifying ways to reduce these negative effects of smoking abstinence may be important in increasing the success of quit attempts. Participation in regular exercise appears to ameliorate the intensity and frequency of many of the TWS and cravings associated with smoking cessation. However, findings from intervention studies designed to investigate if exercise assists individuals to quit smoking have shown mixed results (Ussher et al. 2012). A clearer understanding of the relationships between exercise, TWS, and cravings during temporary smoking abstinence may improve the design, and ideally the effectiveness, of future exercise-based smoking cessation interventions. V. Roberts (*) : R. Maddison : C. Simpson : C. Bullen National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand e-mail: [email protected]H. Prapavessis School of Kinesiology, University of Western Ontario, 1151 Richmond Street, London, ON, Canada N6A 3K7 Psychopharmacology (2012) 222:1–15 DOI 10.1007/s00213-012-2731-z
Transcript
REVIEW
The acute effects of exercise on cigarette cravings, withdrawalsymptoms, affect, and smoking behaviour: systematicreview update and meta-analysis
Vaughan Roberts & Ralph Maddison &
Caroline Simpson & Chris Bullen & Harry Prapavessis
Received: 9 October 2011 /Accepted: 23 April 2012 /Published online: 15 May 2012# Springer-Verlag 2012
AbstractRationale Smoking cessation is associated with cigarettecravings and tobacco withdrawal symptoms (TWS), andexercise appears to ameliorate many of these negativeeffects. A number of studies have examined the relation-ships between exercise, cigarette cravings, and TWS.Objectives The objectives of this study were (a) to reviewand update the literature examining the effects of short boutsof exercise on cigarette cravings, TWS, affect, and smokingbehaviour and (b) to conduct meta-analyses of the effect ofexercise on cigarette cravings.Methods A systematic review of all studies publishedbetween January 2006 and June 2011 was conducted.Results Fifteen new studies were identified, 12 of whichfound a positive effect of exercise on cigarette cravings.The magnitude of statistically significant effect sizes for‘desire to smoke’ and ‘strength of desire to smoke’ rangedfrom 0.4 to 1.98 in favour of exercise compared to passivecontrol conditions, and peaked either during or soon aftertreatment. Effects were found up to 30 min post-exercise.Cigarette cravings were reduced following exercise with awide range of intensities from isometric exercise and yogato activity as high as 80–85 % heart rate reserve. Meta-analyses revealed weighted mean differences of −1.90and −2.41 in ‘desire to smoke’ and ‘strength of desire tosmoke’ outcomes, respectively. Measures of TWS and
negative affect were reduced following light–moderateintensity exercise, but increased during vigorous exercise.Conclusions Exercise can have a positive effect on cigarettecravings and TWS. However, the most effective exerciseintensity to reduce cravings and the underlying mechanismsassociated with this effect remain unclear.
Smoking cessation is associated with tobacco withdrawalsymptoms (TWS) such as sleep disturbance, irritability, poorconcentration, and depressed mood, as well as intense crav-ing for a cigarette (Hughes 2007). Craving, the presence ofwithdrawal symptoms, and weight gain are associated withan increased risk of smoking relapse and impact negativelyon attempts to quit (West et al. 1989; Borrelli et al. 2001).Therefore, identifying ways to reduce these negative effectsof smoking abstinence may be important in increasing thesuccess of quit attempts.
Participation in regular exercise appears to ameliorate theintensity and frequency of many of the TWS and cravingsassociated with smoking cessation. However, findings fromintervention studies designed to investigate if exerciseassists individuals to quit smoking have shown mixedresults (Ussher et al. 2012). A clearer understanding of therelationships between exercise, TWS, and cravings duringtemporary smoking abstinence may improve the design, andideally the effectiveness, of future exercise-based smokingcessation interventions.
V. Roberts (*) : R. Maddison : C. Simpson : C. BullenNational Institute for Health Innovation, University of Auckland,Private Bag 92019,Auckland 1142, New Zealande-mail: [email protected]
H. PrapavessisSchool of Kinesiology, University of Western Ontario,1151 Richmond Street,London, ON, Canada N6A 3K7
Since the publication in 2007 of a systematic review ofstudies examining the acute effects of exercise during tem-porary smoking abstinence (Taylor et al. 2007), a number ofstudies have been published that address this issue. Thepurpose of this paper is twofold. First, we update the liter-ature on the acute effects of exercise on TWS, cravings, andaffect during temporary smoking abstinence, and examinepotential mediators of the exercise–TWS relationship. Forthe purpose of comparing current knowledge to the conclu-sions of an earlier review, we include a summary of thefindings of the previous review and employ methods con-sistent with that review (Taylor et al. 2007). We highlightthe findings of studies published since the previous review,discuss progress made, and the priorities and implicationsfor future research. Second, we conduct a meta-analysis ofall published studies to date to determine more robust esti-mates of the strength of the effect of exercise on selectedcigarette cravings outcomes.
Summary of the previous review
The systematic review by Taylor et al. (2007) identified 14studies published between 1983 and 2006 that examined theeffect of exercise on TWS. Of the 12 studies that comparedexercise with a control condition, all showed at least onepositive effect on withdrawal (Taylor et al. 2007). This wasthe case for both brief (5 to 10 min) bouts of moderateintensity exercise among smokers who were abstinent over-night (Daniel et al. 2004; Ussher et al. 2001) and for 30 to40 min bouts of vigorous intensity among smokers trying toquit (Bock et al. 1999). Withdrawal symptoms found to beaffected by brief bouts of exercise included anxiety, stress,poor concentration, tension, restlessness, and irritability.Nine (Bock et al. 1999; Daniel et al. 2004; Taylor andKatomeri 2007; Taylor et al. 2005, 2006; Thayer et al.1993; Ussher et al. 2001, 2006; Daniel et al. 2006; Katomeri2009) of the ten studies that compared the effects of anexercise condition with a passive condition on cravingsfound a significant reduction in cravings following exercise.Studies that assessed strength of urges to smoke showed thatan average reduction of 1.1 points on a seven-point scalecould be achieved. Three of the studies (Bock et al. 1999;Taylor et al. 2006; Thayer et al. 1993) found that exercisehad a positive effect on mood and affect during smokingabstinence, increasing activation and energy and decreasingnegative affect and tension. One study suggested tensionwas a mediating factor for reductions in desire to smoke(Taylor et al. 2006). The review included four studies thatmeasured time to ad libitum smoking, all of which foundincreases ranging from 8 to 57 min following exercise(Taylor and Katomeri 2007; Thayer et al. 1993; Reeser1983; Katomeri 2009). Except for one study (Bock et al.
1999), which measured cravings throughout a 12-weeksmoking cessation programme, all of the studies measuredcravings and TWS during temporary smoking abstinenceonly, and all were conducted in the laboratory setting.
Taylor et al. (2007) highlighted some key issues to beaddressed in future research. This included the need toincrease the ecologic validity of subsequent findings andto elucidate the mechanisms underpinning the beneficialeffects of exercise on TWS. In regard to this, Taylor et al.surmised that distraction is unlikely to be a mediating factorand proposed that other potential mechanisms such as stressreduction and activation, psychobiological mechanisms, andappetite suppression may be important. The authors sug-gested that exercise may mimic the effects of smoking byboth relaxing and activating the individual. Some evidencepointed to reductions in stress levels playing a part inmediating decreased desire to smoke, but the authors con-sidered more research was needed to examine the relation-ship between exercise and smoking cravings with regard tostress and boredom. Additional research to examine the roleof β-endorphins and opioids as well as dopaminergic activ-ity in the context of exercise and cigarette cravings andTWS was also proposed. Taylor et al. (2007) concluded thata brief bout of exercise can reduce cravings for a cigarette atlevels comparable to those of glucose and oral nicotinereplacement therapy, and should therefore be recommended.Ussher et al. (2012) provide a brief summary of studiesconducted in this area since the review by Taylor et al.(2007). The following review builds on the summary byUssher et al. (2012).
Method
We undertook a systematic search of the literature usingonline searches of the following electronic data bases:Sports Discus, MEDLINE, PubMed, Web of Science,EMBASE, PsycINFO, Cochrane Tobacco Addiction Groupspecialized register, the ETD Digital Library–NetworkedDigital Library of Theses and Dissertations, and ProquestDigital Dissertations. The keywords used were exercise,physical activity, smoking, tobacco, nicotine, smoking ces-sation, withdrawal, craving, and affect. The search waslimited to all studies of human adult participants (≥18 years)published between January 2006 and February 2012. Therewere no specific criteria for study design. The search ofelectronic databases identified 144 studies. The first andthird authors examined the abstracts of all studies. Wherea decision to include or exclude a study could not beattained from the abstract, the full article was reviewed.We contacted prominent researchers in the field and askedfor any studies currently under review or in press. Fourfurther studies were identified. We also hand-searched the
2 Psychopharmacology (2012) 222:1–15
reference lists of relevant articles and abstracts from theSociety for Research on Nicotine and Tobacco annual meet-ings from 2006–2010. Decisions to exclude a study weremade based on the title of the abstract, and the remainingabstracts were reviewed for inclusion. In accordance withthe previous review, we included all journal articles, confer-ence abstracts, theses, and dissertations that studied theeffects of a brief bout of exercise on tobacco withdrawalsymptoms, cravings, or affect during smoking abstinence.
Results
The search yielded 15 new studies (Daniel et al. 2007;Everson et al. 2008; Ho 2009; Janse Van Rensburg et al.2009b; Scerbo et al. 2010; Ussher et al. 2009; Janse VanRensburg et al. 2009a, 2012; Janse Van Rensburg andTaylor 2008; Faulkner et al. 2010; Elibero et al. 2011;Harper 2011; Williams et al. 2011; Arbour-Nicitopoulos etal. 2011). Twelve were published in peer-reviewed journals,and three were from two PhD dissertations. While one of theidentified studies (Taylor and Katomeri 2007) was pub-lished within the time frame, it was included in the previousreview, so was not included in this review. A mix ofbetween-subject parallel design and within-subject cross-over design studies was identified. Four studies (Harper2011; Williams et al. 2011; Arbour-Nicitopoulos et al.2011) examined the acute effects of exercise on cravingsand withdrawal symptoms at certain time points in partic-ipants undergoing a quit attempt. All other studies askedparticipants to temporarily abstain from smoking prior toattending the treatment session. See Table 1 for a detailedsummary of study participant characteristics, treatment con-ditions, study design, measures, and outcomes.
Assessment of study quality and risk of bias was basedon the recommendations by the Cochrane Collaboration(Higgins and Altman 2008). Adequate random sequencegeneration was employed in 14 studies, with the exceptionof the study by Scerbo et al. (2010), which assigned partic-ipants sequentially to each condition based on recruitmentorder. It was unclear in all studies whether allocation totreatment groups was concealed up to the point of random-isation; however, it is likely that the method of concealmentwas not described, rather than there being no method ofconcealment. As participants were assigned to particulartypes/intensities of exercise and/or passive control condi-tions, and may be aware of the expected psychologicalbenefits of exercise, it is not possible to blind participantsto treatment. This potential source of bias could increase themagnitude of the treatment effect in favour of exercise.However, the effect of participant expectation has beenexamined and is discussed with reference to two studies(Daniel et al. 2007; Harper 2011, Study 2) below. All 15
studies were considered free of other potential sources ofbias. Four of the 11 studies that examined cravings duringtemporary abstinence reported conducting a sample sizecalculation a priori (Everson et al. 2008; Faulkner et al.2010; Janse Van Rensburg and Taylor 2008; Scerbo et al.2010), although only two studies (Ho 2009; Arbour-Nicitopoulos et al. 2011) were insufficiently powered todetect a difference between conditions in cravings, suggest-ing that the target sample sizes in the other studies werebased on previous research.
Cigarette cravings
All of the 15 studies measured cravings to smoke. Twelve ofthese found that exercise had a positive effect on cigarettecravings (desire to smoke, strength of desire to smoke, oranticipated pleasure from smoking), with reported immedi-ate effects lasting up to 30 min posttreatment (Daniel et al.2007; Everson et al. 2008; Janse Van Rensburg et al. 2009a,b, 2012; Scerbo et al. 2010; Ussher et al. 2009; Janse VanRensburg and Taylor 2008; Faulkner et al. 2010; Elibero etal. 2011; Harper 2011). One study showed a positive effectof exercise on cigarette cravings during treatment, but notposttreatment (Faulkner et al. 2010). Three studies failed toshow an effect (Ho 2009; Williams et al. 2011; Arbour-Nicitopoulos et al. 2011), although two of these showedtrends in favour of exercise (Williams et al. 2011; Arbour-Nicitopoulos et al. 2011).
The measure of cigarette cravings varied between studies(see Table 1). Self-report was the predominant method usedto measure cravings, but other approaches included picture-based cue reactivity (Elibero et al. 2011), attention bias(increased attention to smoking-related stimuli) (Janse VanRensburg et al. 2009a), and brain activation using functionalMRI (fMRI; Janse Van Rensburg et al. 2009b, 2012). Sig-nificant reductions in cravings were found following exer-cise for all of these measures of cravings, relative to controlconditions and/or relative to baseline.
Ten studies measured either desire to smoke (Tiffany andDrobes 1991) or strength of desire to smoke (SoD; West andHajek 2004) and compared exercise with a control condi-tion. Calculated Cohen’s d effect sizes (Cohen 1992)revealed moderate to large effects of exercise on strengthof desire to smoke, with significant effects ranging from0.40 to 1.48 for four of the studies (Everson et al. 2008;Scerbo et al. 2010; Ussher et al. 2009; Janse Van Rensburget al. 2012). Moderate to large effects were also observed fordesire to smoke, with significant effects ranging from 0.65(Scerbo et al. 2010) to 1.98 (Janse Van Rensburg et al.2012). The magnitude of significant posttreatment effectsizes peaked either during or soon after exercise; however,significant effect sizes were found up to 30 min post-exercise, including 30 min post 15 min walking [effect size
Psychopharmacology (2012) 222:1–15 3
Tab
le1
Sum
maryof
includ
edstud
ies
Study
Sub
jectscharacteristics
Abstin
ence
period
Exercisecharacteristics
Measures
Design
Outcome
(Title)
Danielet
al.
(200
7)22
Mand23
FMean013
hReada(a)
positiv
e(b)
negativ
e(c)
ambigu
ousparagraphabou
ttherelatio
nshipbetweenTWSand
exercise
priorto
10min
ofcyclingbetween40
and
60%
ofHRR
Craving
smeasure–Desire
tosm
oke(Tiffany
)Exp
ectatio
ns–Credibility
ScaleRespo
nse–MPSS
Betweensubject(rando
mly
assign
ed).Assessm
ents–
Exp
ectatio
ns:1month
pre
and20
min
preR
espo
nse:
10,5,
and0min
pre,mid,
andIP,5and10
min
post.
Com
paredrespon
seto
expectations
Exp
ectatio
nmanipulationwas
successful;Nosignificant
differencesin
MPSSor
SoD
betweenexpectationgrou
ps;
Significant
reductionin
symptom
sandSoD
during
andafterexercise
forallg
roup
s(ESrang
edfrom
0.4
to0.8)
Acute
exercise
effectson
smok
ingwith
draw
alsymptom
sanddesire
tosm
okeareno
trelated
toexpectation
Age
016
–65
years
Mean024
Meancigs014
.4perday
MeanFTND04.2
Meanbaselin
eSoD
04.4
Exercise:
VPA
<3tim
esperweekfor>20
min,
orMPA
<5tim
esper
weekfor>30
min
Everson
etal.
(200
8)25
Mand20
FMean017
h10
min(a)cycled
40–59
%HRR(b)cycled
60–84
%HRR(c)Sat
quietly
with
nodistractions
Craving
smeasure–SoD
(West),Other
measures–
MPSSandSEES
Betweensubject(rando
mly
assign
ed,stratifiedfor
gend
er).Assessm
ents:
pre,mid,and5and
30min
post
(aandb)<(c)desireto
smok
edu
ring
and5min
post.(ESdu
ring
0.82
(a),1.15
(b);ES5min
post0.79
(a),1.03
(b)(a)
redu
cedTWSand
improv
edmoo
d5-min
post(b)in-
creasedPD
andMPSS,andre-
ducedhapp
inessscoresNoeffects
at 30min
post
The
effectsof
mod
erate
andvigo
rous
exercise
ondesire
tosm
oke,
with
draw
alsymptom
s,andmoo
din
abstaining
youn
gadultsm
okers
Meanage0
21.8
Meancigs013
.6perday
MeanFTND03.4
Meanbaselin
eSoD
04.6
Exercise:
≤3tim
esper
weekfor>30
min
JanseVan
Rensburgand
Taylor
(200
8)
15M
and8F
15h
15min(a)Brisk
walk(treadmill)
(meanRPE010
.8(1.67)
rang
e6–
20)
(b)Passive
control
Craving
smeasures–Desire
tosm
oke(Tiffany
),10
-item
QSU.Other
measures–Stroo
pTask
reactio
ntim
e
Rando
mised
crossover
design
.Assessm
entspre,
&IP,5-,10
-&
15-m
inpo
stforallmeasures.
Add
ition
alassessmentat
mid
for'desireto
smok
e'&
QSU.
(a)and(b)no
sign
ificantdifference
forStroo
p(a)
redu
ceddesire
tosm
oke,QSU
Factor1and2and
redu
cedcravings
upto
15min
postcf
(b),ESrang
edfrom
.86to
1.02
The
effectsof
acuteexercise
oncogn
itive
functio
ning
andcigarette
cravings
during
tempo
rary
abstinence
from
smok
ing
Meanage0
23.1
Meancigs013
.7perday
MeanFTND03.4
JanseVan
Rensburget
al.
(200
9a)
15M
and5F
15h
15min(a)Cyclin
g(RPE011–13
)(b)
Sittingpassivelywith
nodistractions
Craving
smeasures–
Attentionalbias
measurement,Desire
tosm
oke(Tiffany
)
Rando
mised
crossover
design
.Eye
tracking
protocol
pre-
andpo
sttreatm
ent.Desireto
smok
eassessed
pre-,mid-
andpo
st-treatment,and
post-eye
tracking
protocol
(a)redu
ceddesire
tosm
okemid
(ES01.07
)andpo
st(ES01.06
)treatm
entcf
(b).Dwelltim
eand
initial
fixatio
ntowards
smok
ing
images
wereredu
cedwith
(a)cf
(b)
The
effectsof
acuteexercise
onattentionalbias
towards
smoking-relatedstim
uli
during
tempo
rary
abstinence
from
smok
ing
Meanage0
29.05
Meancigs015
.6perday
MeanFTND04.0
Meanbaselin
edesire
tosm
oke0
5.3
JanseVan
Rensburget
al.
(200
9b)
10M
andF
15h
10min(a)Cyclin
g(RPE011–13
)(b)
Sittingpassivelywith
nodistractions
Craving
smeasures–fM
RI
brainactiv
ation,
Desire
tosm
oke(Tiffany
)
Rando
mised
crossover
design
.10
min
exercise
then
15min
fMRIscanner.
Desireto
smok
eassessed
pre-,mid-,and
posttreatm
ent
Scann
ingfoun
ddecreasedactiv
ation
inareasof
thebrainassociated
with
reward,
motivation,
and
visuospatialattentionafter(a)cf
(b).(a)redu
ceddesire
tosm
oke
mid-(ES0.88)
andpo
sttreatm
ent
(ES01.14
)cf
(b)
Acute
exercise
modulates
cigarette
cravings
and
brainactiv
ationin
respon
seto
smok
ing-relatedim
ages:
anfM
RIstud
y
Age
018
–50
Meancigs013
.7perday
MeanFTND03.4
Meanbaselin
edesire
tosm
oke0
4.6
Ussheret
al.
(200
9)31
Mand17
FMean016
.7h
10min(a)Bod
yscan(b)Isom
etric
exercise
(jaw
clenching,
fist
clenching,
pushingthepalm
sof
thehand
stogether,pu
shingdo
wn
onthethighs,squeezingthighs
together,pu
shingfeet
into
the
floo
r)(c)Listening
toan
audio-
recordingof
anaturalhistorytext
Craving
smeasure–SoD
(West)Other
measures–
MAAS,mod
ifiedMPSS,
perceivedcredibility
Betweensubjects(rando
mly
assign
ed).Assessm
entpre
andIP,5,
10,and30
min
post-interventionin
the
labo
ratory
andthen
under-
took
interventio
nagain
during
next
3hin
their
‘normal’environm
ent
assessed
preandIP,5and
30min
post-intervention
Desireto
smok
eandwith
draw
alsymptom
sredu
cedin
(aandb)
cf(c)forup
to30
min
postin
lab
setting
(ESrang
edfrom
.61to
.94),andup
to5min
postin
‘normal’setting
.Nosign
ificant
difference
between(a)and(b)
Effectof
isom
etricexercise
andbo
dyscanning
oncigarette
cravings
and
with
draw
alsymptom
s
Meanage0
27.8
Meancigs015
.5perday
MeanFTND05.0
4 Psychopharmacology (2012) 222:1–15
Tab
le1
(con
tinued)
Study
Sub
jectscharacteristics
Abstin
ence
period
Exercisecharacteristics
Measures
Design
Outcome
(Title)
Ho(200
9)8M
24h
(a)resistance
exercises(6
exercises,
3×10
ofeach)(b)
quietrest(c)rest
(and
adlib
itum
smok
ing)
Craving
smeasureSoD
(West)Other
measures–(1)
serum
cotin
ine,(2)plasma
ACTH,(3)plasmacortisol,
(4)saliv
acortisol,(5)HR,
(6)SBPand(7)DBP,(8)
MPSS,(9)PA
SAT
Rando
mised,crossover
design
.Abstained
from
4p.m.,then
treatm
entthe
next
morning
,then
mental
challeng
ein
theafternoo
n.Assessm
entspre-a.m.,IP-
a.m.,30
min
post-a.m
.,andpre-p.m.,IP-p.m
.,30
min
post-p.m
.
(a)elevated
(2,3,
5,and7)
atIP-a.m
.cf
(bandc)(2,3,
4)at
pre-p.m.no
significantdifference
between(a)and(b)(a)
show
edno
sign
ificantdifference
forSoD
,MPSSof
PASAT
Effectsof
resistance
exercise
oftheHPA
axisand
cardiovascular
respon
sesto
psycho
logicalstress
during
short-term
smok
ing
abstinence
inmen
Meanage0
20.1
Smok
e≥1
0perday
Inactiv
e
Scerboet
al.
(201
0)10
Mand8F
3h
15min(a)runn
ing(80–85
%HRR)
(b)walking
(45–50
%HRR)(c)
sitting
onachairon
atreadm
ill
Craving
smeasuresD
esire
tosm
oke(Tiffany),SoD
(West)Other
measures–
HR,saliv
arycortisol
Rando
mised
crossover
design
.SoD
assessed
pre,
mid,IP,10
,20,and30
min
posttreatm
ent.Salivary
cortisol
assessed
pre,IP,
and30
posteach
treatm
ent
(aandb)
redu
cedSoD
cf(c)(sig
ES
rang
edfrom
0.4to
1.48
).No
sign
ificantdifference
between(a)
and(b)forSoD
,bu
teffectslasted
long
erwith
(a).(a)on
ly,
attenu
ated
thedeclinein
cortisol
concentrations
Effectsof
exercise
oncravings
tosm
oke:
therole
ofexercise
intensity
andcortisol
Meanage0
26
Meancigs013
.9perday
MeanFTND04.4
Meanph
ysical
activ
ity0
171min
perweek
Faulkneret
al.
(201
0)11
Mand8F
Mean08h
10min(a)self-paced
briskwalking
(meanRPE011.89(1.79),rang
e6–
20)(b)
passivelysitting
ona
chairbeside
atreadm
ill
Craving
smeasure–Desire
tosm
oke(Tiffany),Other
measures–Smok
ing
topo
graphy
(puffvo
lume,
puffdu
ratio
n,pu
ffcoun
t,interpuffinterval,tim
eto
firstpu
ff)HR
Rando
mised
crossover
design
.Desireto
smok
eassessed
pre,mid,IP,10
,and20
min
posttreatm
ent.
Smok
ingtopo
graphy
assessed
20min
aftereach
treatm
ent
(a)redu
ceddesire
tosm
okecf
(b)
mid
cond
ition
(ES0.98),bu
tno
tpo
st-con
ditio
n.(a)siglong
ertim
eto
firstpu
ffcf
(b)Trend
sin
favo
urof
(a)forother
topo
graphy
outcom
es
Cuttin
gdo
wnon
epu
ffat
atim
e:theacuteeffectsof
exercise
onsm
oking
behaviou
r
Meanage0
25
Meancigs015
.2perday
MeanFTND04.5
Meanph
ysical
activ
ity0
171min
perweek
Elib
eroet
al.
(2011)
76M
andF
1h
30min(a)walking
onatreadm
ill(65–75
%HRR)(b)
Hatha
yoga
(asanasinclud
edbridge,forw
ard
bend
,table,cow,cobra)(c)
view
avideoabou
texercise
Cravingsmeasure(s)–
QSU-brief,apicture-
basedcuereactiv
ityassessmentOther
measures–abrief
moo
dform
Betweensubject(rando
mly
assign
ed).Assessm
entpre
andIP,and20
min
post
(aandb)
redu
cedQSU
Factor1cf
(c).(a)show
eddecreasedcraving
towardsm
okingpictures
but
increasedtowardneutralpictures.
(b)show
eddecreasedcraving
towardbo
thpictures.(c)show
edincreasedcravingtowardbo
thtypesof
cues
Acute
effectsof
aerobic
exercise
andhathayo
gaon
cravingto
smok
eMeanage0
29
Meancigs020
perday
Harper(2011)
Study
1119F
(a)1week,
(b)7
weeks,and(c)
10weeks
postqu
itdate
20min
onchoice
oftreadm
ill,
rowingmachine,stairclim
ber,
orstationary
bike.(a)
mod
erate-
intensity
exercise
(50–60
%HRR)(b)
vigo
rous-intensity
exercise
(>70
%HRR)(c)
vigo
rous-intensity
exercise
(>70
%HRR)
Craving
smeasure–
Shiffman–Jarvik
with
draw
alscale
Sub
-study
ofexercise+NRT
smok
ingcessation
interventio
ntrial.
Assessm
entpreandIP
Significant
redu
ctions
incraving
wereob
served
follo
wingexercise
attim
epo
ints(a),(b),and(c)and
psycho
logicalwith
draw
aland
sedatio
nat
(a)and(b)
Exerciseprov
ides
further
cravingandwith
draw
alreliefforrecently
quit
wom
enwho
areusing
nicotin
ereplacem
ent
therapy
Meanage0
41
Meancigs017
perday
Harper(2011)
Study
258
F1weekpo
stqu
itdate
20min
onchoice
oftreadm
ill,
rowingmachine,stairclim
ber,
orstationary
bikeModerate-
intensity
exercise
(50–60
%HRR)Participantscatego
rised
into
HighEX-EXPandLow
EX-EXP,andHighEX-CRED
andLow
EX-CRED
Craving
smeasure–
Shiffman–Jarvik
with
draw
alscaleOther
measures–ECQ
Sub
-study
ofexercise+NRT
smok
ingcessation
interventio
ntrial.ECQ:
pre.With
draw
alscale:
pre
andIP
HighEX-EXP>redu
ctionin
cravingfollo
wingexercise
cfLow
EX-EXP.HighEX-CRED>
reductionin
cravingfollo
wing
exercise
cfLow
EX-CRED
Ex-Exp
andEx-Credaffects
cravingbu
tno
tTWS
Meanage0
43
Meancigs018
perday
Arbou
r-Nicito
poulos
etal.(2011)
14M
andF
Mean07.84
ha)
10min
briskwalking
ona
treadm
illb)
10min
sitting
passivelyon
achairbeside
atreadm
ill
Craving
smeasure–Desire
tosm
oke(Tiffany)O
ther
measures–PA
R-Q
,MPSS,
Feelin
gscale(H
ardy
and
Rejeski
1989
),Felt
arou
salscale(Svebak
andMurgatroy
d19
85)
Rando
mised
crossover
design
.Pilo
tstud
yam
ong
individu
alswith
SMI
participatingin
asm
oking
cessationprog
ramme.All
measurespre,mid,IP,10
,and20
min
post
Nosign
ificantmaineffectswere
foun
dfortim
eor
cond
ition
for
cravings.Sig
time×
cond
ition
interactionforaffectivevalence:
(a)feltmorepleasant
than
(b).
(a)>activ
ationthan
(b).No
sigeffectson
MPSSou
tcom
es
Apilotstud
yexam
iningthe
acuteeffectsof
exercise
oncigarette
cravings
and
affect
amon
gindividu
als
with
seriou
smentalillness
Meanage0
50
Meancigs010
MeanFTND04.71
Psychopharmacology (2012) 222:1–15 5
(ES)00.4 (desire to smoke) and 0.92 (SoD) (Scerbo et al.2010)] and 30 min post-isometric exercise [ES00.69 (SoD)(Ussher et al. 2009)].
A number of studies compared different intensities ofexercise. Two studies (Everson et al. 2008; Scerbo et al.2010) compared the effect of moderate intensity versusvigorous intensity exercise on cravings (see Table 1 fordetails of treatment protocols for the exercise intensity ineach study) and showed similar effects on desire to smoke.There were no significant differences between the effects ofmoderate and vigorous intensity exercise on cravings ineither study, although both studies found significant differ-ences between both exercise conditions and the passivecontrols.
Harper (study 1) also assessed the effects of acute boutsof both moderate and vigorous intensity exercise on crav-ings, but did not conduct a direct comparison between thetwo intensities. In a sample of female smokers participatingin a 14-week exercise-aided nicotine replacement therapy(NRT) programme for smoking cessation, cravings (mea-sured with the Shiffman–Jarvik withdrawal scale; Shiffmanand Jarvik 1976) were assessed before and after an exercisetreatment session (see Table 1 for details of each exercisesession) at week 5 (1-week post quit date and on 21-mgNRT patch), week 11 (7 weeks post quit date and on 14-mgNRT patch), and week 13 (9 weeks post quit date and on7-mg NRT patch). Significant reductions in cravings frompre- to post-exercise were found at all three time points (i.e.week 5, ǹ20 .294; week 11 ǹ20 .252; and week 13,ǹ20 .153). In an actual quit attempt involving NRT, cravingrelief following an acute bout of exercise can be achieved.
Two studies examined light-intensity yoga (Elibero et al.2011) and isometric exercise (Ussher et al. 2009) and foundstatistically significant reductions on cravings to smoke.Elibero et al. (2011) compared three conditions, 30 min ofyoga, 30 min of moderate intensity [70 % of maximum heartrate (HR)] walking on a treadmill, and a passive controlgroup, and showed that both exercise groups significantlydecreased urges to smoke (measured with the QSU-brief,Cox et al. 2001) compared to the control group. Relative tothe control group, who increased cravings when presentedwith both smoking and neutral images, cravings werereduced in both exercise groups in response to smoking-related images, and in the yoga group in response to neutralimages. Ussher et al. (2009) showed a significant reductionin cravings following a 10-min isometric exercise.
One study examined the effect of resistance-based exer-cise (back squat, bench press, bent-over row, arm curl,Romanian deadlift, and sit ups) and reported no significantdifference in cravings to smoke, compared to a passivecontrol group (Ho 2009); although with small to moderateeffect sizes (0.26–0.44) posttreatment, this was perhaps dueto being underpowered. This is the only study to date toT
able
1(con
tinued)
Study
Sub
jectscharacteristics
Abstin
ence
period
Exercisecharacteristics
Measures
Design
Outcome
(Title)
Williamset
al.
(2011)
60F
Eachcontact
(3×perweek)
througho
utan
8-weeksm
oking
cessation
prog
ramme
(a)50
min
briskwalking
ona
treadm
ill,3×
perweek(b)
30min
watchingvideos
onhealth
andlifestyle
issues,3×
perweek
Craving
smeasure–Desire
tosm
oke(Shiffman
etal.
2003)Other
measures:
The
ADACL
Between-subjectsdesign
RCT.
Assessedcravings
andaffect
preandIP
treatm
entat
each
session
throug
hout
an8-week
smok
ingcessation
prog
rame
Non
sign
ificanttrendtowardtim
e×treatm
entinteractionforcravings:
(a)<
(b).Significant
time×
treatm
entinteractionforenergy
andtiredness
infavo
urof
(a).No
effect
ontensionor
calm
ness
Acute
effectsof
mod
erate-
intensity
aerobicexercise
onaffectivewith
draw
alsymptom
sandcravings
amon
gwom
ensm
okers
Meanage0
42
Smok
e≥5perday
MeanFTND04.8
JanseVan
Rensburget
al.
(201
2)
20M
andF
15h
10min(a)Cyclin
g(RPE011–13
)(b)Sittingpassivelywith
nodistractions
Craving
smeasures–fM
RI
brainactiv
ation,
Desire
tosm
oke(Tiffany
),SoD
(West)
Rando
mised
crossover
design
;10
min
exercise
then
15min
fMRIscanner.
Desireto
smok
e,SoD
assessed
pre-,mid-,and
posttreatm
ent
Scann
ingfoun
dincreasedactiv
ation
inareasof
thebrainassociated
with
visual
processing
after(b)cf
(a).(a)redu
ceddesire
tosm
oke
mid
(ES01.96
)andpo
st(ES0
1.98
)treatm
ent,andSoD
mid
(ES01.27
)andpo
st(ES01.31
)treatm
ent,cf
(b)
The
acuteeffectsof
exercise
oncigarette
cravings
and
brainactiv
ationin
response
tosm
oking-relatedim
ages:
ablock-design
fMRIstud
y
Age
018
–50
Meancigs012
.3perday
MeanFTND02.3
Meanbaselin
edesire
tosm
oke0
5.3
Mmale,Ffemale,RPEratin
gof
perceivedexertio
n,So
DStrengthof
Desireto
smok
e,MPSS
Moo
dandPhy
sicalS
ymptom
sScale,S
EESSub
jectiveExerciseExp
erienceScale(PDpsycho
logical
distress,P
WBpo
sitiv
ewell-being),IP
immediately
post,E
Seffect
size,H
RRheartrate
reserve,TWStobaccowith
draw
alsymptom
s,10
-QSU
10-questionQuestionn
aire
onSmok
ingUrges,fM
RI
functio
nalmagnetic
resonanceim
aging,
MAASMindful
AttentionAwarenessScale,ACTH
adreno
corticotropicho
rmon
e,SB
Psystolic
bloo
dpressure,DBPdiastolic
bloo
dpressure,SV
-POMS
Sho
rtened
Version
oftheProfileof
Moo
dStateQuestionn
aire,P
ASA
TPaced
Aud
itory
SerialAdd
ition
Task,
HRheartrate,E
CQ
treatm
entexpectancy
andcredibility
questio
nnaire,H
ighEX-EXP
high
exercise
expectancy
grou
p,Low
EX-EXPlow
exercise
expectancy
grou
p,HighEX-CRED
high
exercise
credibility
grou
p,Low
EX-CRED
low
exercise
credibility
grou
p,PA
R-Q
Phy
sical
Activity
Readiness
Questionn
aire,SM
Iseriou
smentalillness,ADACLThe
Activation–
DeactivationAdjectiv
eChecklist
6 Psychopharmacology (2012) 222:1–15
have examined resistance exercise in this context, and fur-ther research is required to examine the effects of resistanceexercise.
Two studies sought to determine whether reductions incravings post-exercise were related to participant’s outcomeexpectancy by either manipulating (Daniel et al. 2007) orpredetermining (Harper 2011, Study 2) participants’ expec-tancy of an effect of exercise on cravings (see Table 1 forstudy designs). Both studies demonstrated significant differ-ences between pre- and post-exercise craving scores. How-ever, whereas Daniel et al. found no differences betweengroups, Harper showed significantly greater reductions incravings in those categorised as high in exercise expectancycompared to those considered low in exercise expectancy.Significantly greater reductions were also observed for thoseclassified as high versus low credibility.
Tobacco withdrawal symptoms
Withdrawal symptoms known to be reduced by exerciseinclude irritability, depression, tension, restlessness, difficul-ty concentrating, and stress. Seven studies measured TWSusing either the Mood and Physical Symptoms Scale(MPSS; West and Hajek 2004) (Daniel et al. 2007; Eversonet al. 2008; Ho 2009; Ussher et al. 2009; Arbour-Nicitopoulos et al. 2011) or the Shiffman–Jarvik withdrawalscale (Shiffman and Jarvik 1976); (Harper 2011). Three(Daniel et al. 2007; Everson et al. 2008; Ussher et al.2009) out of the five studies (Daniel et al. 2007; Eversonet al. 2008; Ho 2009; Ussher et al. 2009; Arbour-Nicitopoulos et al. 2011) that measured TWS with theMPSS (West and Hajek 2004) found a positive effect ofexercise on at least one withdrawal symptom. Of these threestudies, two compared exercise with a passive control con-dition, and both found a significant difference betweenconditions in favour of exercise: isometric exercise (Ussheret al. 2009) and moderate-intensity cycling (Everson et al.2008). In contrast, increased composite MPSS scores werefound during bouts of vigorous intensity exercise, suggest-ing an adverse effect on symptoms; however, these adverseeffects were not evident after exercise (Everson et al. 2008).Harper (Study 1, 2011) showed that 20 min bouts of mod-erate intensity exercise at week 5 of an exercise-aided NRTsmoking cessation programme and vigorous intensity exer-cise at week 11 of the programme significantly reducedpsychological and sedation withdrawal symptoms frompre- to post-exercise. Differences between pre- and post-exercise scores for these withdrawal symptoms at week 13also approached significance (p00.083).
Two studies examined whether reductions in TWS post-exercise were related to participant’s outcome expectancy(Daniel et al. 2007; Harper 2011, Study 2). Both studiesdemonstrated significant differences between pre- and post-
exercise TWS scores; however, there were no differencesbetween groups for outcome expectancy. It is worth noting,however, that in the study by Harper, those in the highexercise expectancy and high exercise credibility groupsexperienced greater reductions in withdrawal symptomsfollowing exercise than those in the low expectancy andcredibility groups, although these were not statisticallysignificant.
Janse Van Rensburg and Taylor (2008) assessed theeffects of exercise (15 min self-paced walk) on impairedconcentration by measuring cognitive function using theStroop Task (Stroop 1935). While no significant group bytime interaction or main effect of condition for Stroop Taskreaction time was found, between condition t tests at eachtime point revealed significantly lower mean reaction timescores at 10 and 15 min post-exercise compared to those inthe passive control group. This study represented a method-ological improvement compared to previous self-reportedmeasures of concentration.
Affect
Four (Elibero et al. 2011; Everson et al. 2008; Williams etal. 2011; Arbour-Nicitopoulos et al. 2011) of the five studies(Elibero et al. 2011; Everson et al. 2008; Ho 2009; Williamset al. 2011; Arbour-Nicitopoulos et al. 2011) that examinedthe effect of exercise on affect found a positive effect ofexercise on at least one measure of affect. Elibero et al.(2011) showed that positive affect increased and negativeaffect decreased immediately after both 30 min of yoga and30 min of moderate-intensity walking, and Everson et al.(2008) found that positive well-being was increased andpsychological distress was decreased 5 min after 10 min ofmoderate-intensity cycling. These results are consistent withfindings from the previous review (Taylor et al. 2007).However, Everson et al. (2008) also found that positivewell-being decreased and psychological distress increasedduring the vigorous exercise condition, mimicking the trendfor composite MPSS score, described above. Using theActivation–Deactivation–Adjective–Checklist (ADACL;Thayer, 1989), Williams et al. (2011) found significanttime×treatment interaction effects for energy and tiredness,such that exercise (50 min brisk walking) participantsreported higher mean energy and lower mean tirednesscompared to control participants posttreatment, comparedwith no differences pretreatment. Conversely, they found nosuch effects for tension or calmness. Finally, Arbour-Nicitopoulos et al. (2011) found a significant time×condi-tion interaction effect for affective valence (pleasure–displeasure) using the one-item Feeling Scale (Hardy andRejeski 1989), but no interaction effect for activation (mea-sured using the one-item Felt Arousal Scale(Svebak andMurgatroyd 1985)).
Psychopharmacology (2012) 222:1–15 7
Smoking topography or behaviour
Only one study examined the effect of exercise on smokingtopography (Faulkner et al. 2010). Using the ClinicalResearch Support System Pocket, a computer-based hand-held unit which automatically measures smoking behaviourparameters (Plowshare Technologies,® Borgwalt KC, Inc.,VA), Faulkner et al. (2010) measured a variety of smokingbehaviour outcomes following either a 10-min brisk walk-ing or passive sitting. The time to first puff was significantlylonger following the brisk walking condition than followingpassive sitting, and there were trends towards significanteffects in favour of walking for all of the other smokingtopography outcomes. These preliminary findings suggestthat participating in regular light-to-moderate exercise mayhelp lengthen the time between each cigarette, and thusdecrease the number of cigarettes smoked per day, whichmay assist in smoking cessation. However, more research isrequired with larger sample sizes, greater periods of absti-nence, and less active smokers, as the authors suggest(Faulkner et al. 2010).
Psychobiological biomarkers
Based on previous recommendations (Taylor et al. 2007),two studies have examined the effect of exercise on psycho-biological variables and their mechanistic role on the exer-cise–craving relationship. Scerbo et al. (2010), reported thatthe normal cortisol decrease during abstinence from ciga-rettes was attenuated by a 15-min bout of vigorous intensityrunning, for up to 30 min post-exercise, and Ho (2009)found that plasma adrenocorticotropic hormone (ACTH),serum cortisol, heart rate, and systolic blood pressure wereall elevated post-resistance exercise when compared to botha passive condition during abstinence and in an ad libitumsmoking condition. However, neither study found a rela-tionship between these changes in biomarkers and changesin tobacco cravings or withdrawal.
Meta-analyses
All studies published to date, including those reviewed byTaylor et al. (2007), were reviewed for inclusion in a meta-analysis of the effect of exercise on cigarette cravings duringtemporary abstinence. Due to the heterogeneity of cravingoutcomes across studies, it was not possible to combine alltrial data in one meta-analysis to provide overall summarystatistics for cigarette cravings. However, there were suffi-cient similar trials to conduct meta-analyses for two out-comes, desire to smoke (Tiffany and Drobes 1991) andstrength of desire to smoke (West and Hajek 2004). Authorsof studies which measured these outcomes but did not reportmeans and standard deviations were contacted and asked to
provide this information. Following exhaustive attempts tocontact the authors, we were unable to obtain these essentialdescriptive data for two studies (Daniel et al. 2004, 2006).
No studies reported change in mean (and standard devi-ation) for desire to smoke or strength of desire to smokefrom baseline to posttreatment. These data were thereforeimputed according to the methods outlined by the CochraneHeart Group for handling continuous variables (CochraneHeart Group). The change in mean from baseline to post-treatment for each condition was calculated by subtractingthe mean at follow-up (zero or 5 min posttreatment, depend-ing on when the outcome was measured in each study) fromthe mean at baseline. The standard deviation of the differ-ence (SD difference) was calculated with the followingformula:
SD difference ¼ standard error SEð Þ difference �pn
Where, SE difference0p
SD21 n1 þ SD2
2 n2 � 1� rð Þ=�� �
Where,
SD1 The standard deviation at baselinen1 The number at baselineSD2 The standard deviation at follow-upn2 The number at follow-upr The correlation coefficient
For the correlation coefficient, in the absence of largeepidemiological studies in this area, a value of 0.5 wasassumed (Follmann et al. 1992). These data are presentedin Table 2.
To incorporate within-subject design studies into a meta-analysis with parallel group trials, the mean difference of thetreatments and the corresponding standard error are required(Curtin et al. 2002; Elbourne et al. 2002; Higgins et al.2008). Using the imputations above, the mean differencein change from baseline to follow-up between groups wasthen calculated using the following formula:
M diffð Þ ¼ ME �MC
Where:
M(diff) The mean difference between groupsME Exercise group mean (baseline)−exercise group
mean (follow-up)MC Control group mean (baseline)−control group
mean (follow-up)
For within-subject design studies, the treatment effectwas defined as the mean within-subject difference betweenconditions in change from baseline to follow-up, assumingno carry-over effect. As the studies did not report the meandifference in change from baseline between conditions, thestandard error for the within-subject differences could not beextracted. Therefore, the standard error for the within-
8 Psychopharmacology (2012) 222:1–15
subject trials was imputed according to the guidelines inthe Cochrane Handbook for Systematic Reviews ofInterventions (Higgins et al. 2008), which state thatwhen the standard deviation of the difference betweengroups is not reported, the standard error for the within-person differences [SE (MD)] can be imputed using thefollowing formula:
SEðMDÞ ¼ SDdiffpn=
Where, SDdiff ¼ pSDE
2 þ SDC2 � 2� r � SDE � SDCð Þ
Where,
SDdiff The standard deviation of the within-person differ-ences between conditions
SDE The standard deviation of the difference betweenbaseline and follow-up in the experimental (exer-cise) group
SDC The standard deviation of the differences betweenbaseline and follow-up in the control group
r The correlation coefficient
The correlation between treatment outcomes was approx-imated using a conservative estimate of the correlation co-efficient (r00.62) based on the difference between treatmentgroup means, p values, and t statistics, at 0 or 5 min post-treatment, from trials included in the meta-analyses thatreported this information. Several different correlationcoefficients were imputed as part of sensitivity analyses(Higgins et al. 2008). The corresponding standard errorwas then calculated, as described in the CochraneHandbook for Systematic Reviews of Interventions(Higgins et al. 2008).
The generic inverse variance method, with a randomeffects model applied, was used to combine both between-and within-subject design studies in the meta-analyses(Higgins et al. 2008). Data synthesis and statistical analyseswere conducted using the Cochrane Collaboration ReviewManager (RevMan, version 5.1; The Cochrane Collabora-tion, Copenhagen, Denmark). When multiple comparisonswere conducted within one study (i.e. Everson et al. 2008;Scerbo et al. 2010), the moderate-intensity condition wasincluded in the meta-analyses as moderate-intensity exercise
Table 2 Mean and standard deviation (SD) at baseline and follow-up, and the calculated change in mean and SD from baseline to follow-up, forexercise and control conditions
Exercise Control
Baseline Follow-up Difference n Baseline Follow-up Difference n
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Desire to smoke
Taylor et al. 2006 6.10 1.60 1.20 0.40 −4.90 1.17 15 6.20 1.00 5.50 1.60 −0.70 1.33 15
Janse Van Rensburg et al. 2009a 5.10 1.75 3.15 2.20 −1.95 1.99 20 5.40 1.35 5.05 1.50 −0.35 1.43 20
Janse Van Rensburg et al. 2009b 4.80 0.47 3.10 1.52 −1.70 1.13 10 4.40 0.58 4.80 1.69 0.40 1.26 10
was the predominant exercise intensity examined by theother included studies (Fig. 1).
A total of ten trials (Janse Van Rensburg et al. 2009a, b,2012; Janse Van Rensburg and Taylor 2008; Scerbo et al.2010; Taylor and Katomeri 2007; Taylor et al. 2006; Ussheret al. 2001; Faulkner et al. 2010; Arbour-Nicitopoulos et al.2011) compared the difference between exercise and a pas-sive control condition for desire to smoke. The weightedmean difference in self-reported desire to smoke betweenexercise and control conditions was −1.90 points on aseven-point scale in favour of exercise (95 % confidenceinterval (CI), −3.06 to −0.75; p00.001). A random effectsmodel was used as significant heterogeneity was indicated(I2098 %, p0<0.00001). Sensitivity analyses revealed that,based on effect size, five studies were responsible for theheterogeneity (Faulkner et al. 2010; Taylor et al. 2006;Ussher et al. 2001; Janse Van Rensburg and Taylor 2008;Arbour-Nicitopoulos et al. 2011). When excluding all fivestudies from the analysis, the I2 statistic was reduced from98 to 5 % (p00.38). The pooled reduction in desire tosmoke changed only slightly with the five studies excluded(−2.13, 95 % CI, −2.41 to −1.84; p<0.00001; Fig. 2).
A total of nine trials (n0295) (Everson et al. 2006, 2008;Scerbo et al. 2010; Taylor and Katomeri 2007; Taylor et al.2005; Ussher et al. 2006; Ussher et al. 2001, 2009; JanseVan Rensburg et al. 2012) compared the difference betweenexercise and a passive control condition for strength ofdesire to smoke. The weighted mean difference in self-reported strength of desire to smoke between exercise andcontrol conditions was −2.41 points on a seven-point scalein favour of exercise (95 % CI, −3.45 to −1.37; p<0.00001).A random effects model was used as significant heteroge-neity was indicated (I2094 %, p<0.00001). Sensitivity anal-yses revealed that, based on effect size, two studies wereresponsible for the heterogeneity (Ussher et al. 2001; Tayloret al. 2005), both of which reported large reductions instrength of desire to smoke. When excluding these twostudies from the analysis, the I2 statistic was reduced from94 to 0 % (p00.63). The pooled change in strength of desire
to smoke with the two studies excluded was reducedto −1.74 (95 % CI, −2.05 to −1.44; p<0.00001). One study(Ho 2009), which measured strength of desire to smoke, wasnot included as a six-point scale was used.
Discussion
The overall goal of this paper was to update the evidenceregarding the effect of exercise on the acute effects ofexercise on TWS, cravings, and affect during temporarysmoking abstinence, and to examine potential mediators ofthe exercise–TWS relationship. The evidence to date sug-gests that brief bouts of exercise decrease cravings forcigarettes at rates comparable to nicotine replacement ther-apy (Taylor et al. 2007). The duration of the effect ofexercise on cravings ranged from 5 to 30 min post-exercise. This was the case for both moderate- andvigorous-intensity exercise, and very light-intensity exer-cise. However, the duration of the effect post-exercise needsfurther investigation, particularly in real-life situations. Todate, only one study (Ussher et al. 2009) has examined boutsof exercise performed in the participants’ normal environ-ment, rather than a controlled laboratory setting. In thisstudy (Ussher et al. 2009), duration of effect post-isometricexercise decreased from 30 min when performed in thelaboratory to 5 min in the participants’ normal environment.Future studies should be conducted in more ecologicallyvalid settings.
The magnitude of the effects of exercise on cravings isencouraging. Meta-analyses suggest that exercise is moreeffective than passive control conditions at reducing bothdesire to smoke and strength of desire to smoke, withweighted mean differences between exercise and controlgroups on a seven-point scale of −1.90 and −2.41, respec-tively. Only two of nine studies that measured strength ofdesire to smoke on a seven-point scale failed to show astatistically significant difference between exercise and pas-sive control conditions at zero or 5 min post-condition
Fig. 1 Meta-analysis of trials comparing exercise and control conditions with change in desire to smoke from baseline to between 0 and 5 minposttreatment as the outcome measured
10 Psychopharmacology (2012) 222:1–15
(Everson et al. 2006; Ussher et al. 2006). Ussher et al. (2006),however, did show a significantly greater reduction in theexercise group than the control group, relative to baseline, atthese time points. The second study (Everson et al. 2006),which also failed to show an effect, was conducted with asample of 16–19-year-old adolescents, and the authors sur-mised that 10 min of moderate intensity exercise, previouslyfound to be effective in adult populations (Daniel et al. 2004;Ussher et al. 2001), may not be sufficient to produce reduc-tions in cigarette cravings in younger smokers.
Thus far, research has shown that light-, moderate-, andvigorous-intensity exercise all have a positive effect oncravings, although the duration and magnitude of theseeffects have been shown to vary across studies. Despite this,there has been increased interest in the potential role oflight-intensity activities as a means to reduce cravings. Therationale is that if light-intensity activities are equally aseffective at reducing cravings as higher-intensity exercise,this may be more tolerable and sustainable for smokers.Moreover, light-intensity exercise-based smoking cessationprogrammes may result in greater uptake and adherencethan moderate- or vigorous-intensity exercise programmes,particularly if they can be incorporated into the daily routineand performed in the workplace like the isometric exercisesexamined by Ussher et al. (2009). A variety of light-intensity exercise formats have been examined includingyoga (Elibero et al. 2011) and isometric exercise (Ussheret al. 2009), both of which had positive effects on cravingspost-exercise. In addition, there has also been an increasedfocus on walking as a moderate-intensity activity. Althoughthe magnitude of the effects reported suggests that moderateand vigorous exercise have a much greater effect on tobaccocravings than light exercise, the duration of the effect is alsoimportant. It is noteworthy that all the significant differencesin cravings between exercise and control conditions at 30-min posttreatment were for light- to moderate-intensity exer-cises (walking (Scerbo et al. 2010) and isometric exercise(Ussher et al. 2009)). In summary, exercise is effective forreducing cigarette cravings, but given that the various
intensities of exercise appear to influence the magnitudeand duration of effects in different ways, the most meaning-ful and sustainable exercise approach for increasing quitrates remains unclear.
Increased consistency in measurement tools used wouldstrengthen the body of research and improve comparabilitybetween studies. Many studies (Everson et al. 2006, 2008;Ho 2009; Janse Van Rensburg et al. 2009a, b, 2012; JanseVan Rensburg and Taylor 2008; Scerbo et al. 2010; Taylorand Katomeri 2007; Taylor et al. 2006; Ussher 2006; Ussheret al. 2009; Arbour-Nicitopoulos et al. 2011) have used oneor both of the Tiffany (‘I have a desire for a cigarette rightnow’—predominantly rated on a seven-point scale from1–strongly disagree to 7–strongly agree; Tiffany and Drobes1991) and West questions (‘the strength of my desire tosmoke right now is…’ predominantly rated on a seven-point scale from 1–very weak to 7–very strong; West andHajek 2004). However, there were variations between stud-ies in the number of points on the scale, and the anchorsused for these items, with some studies employing six-pointscales and/or altering the scale response anchors to ‘1–not atall to 7–extremely’. There were also differences betweenstudies in the measurement of prescribed exercise intensity.While some studies (Daniel et al. 2007; Everson et al. 2008;Harper 2011; Scerbo et al. 2010; Ussher et al. 2009; Eliberoet al. 2011) reported percentage of heart rate reserve (HRR),others (Faulkner et al. 2010; Janse Van Rensburg et al.2009a, b, 2012; Janse Van Rensburg and Taylor 2008;Arbour-Nicitopoulos et al. 2011) reported ratings of per-ceived exertion (RPE) while also reporting mean heart rate.These differences in approaches make it difficult for com-parison between studies.
Possible mechanisms
In their previous review, Taylor et al. (2007) discussedpotential mechanisms that may explain why exercise alle-viates tobacco cravings. Mechanisms identified includedaffect hypotheses such as stress reduction and activation,
Fig. 2 Meta-analysis of trials comparing exercise and control condition with strength of desire to smoke as the outcome measured between 0 and5 min posttreatment
Psychopharmacology (2012) 222:1–15 11
biological hypotheses such as β-endorphins, cortisol, oropioids, and cognitive hypotheses such as distraction. Sincethe Taylor et al. review, seven studies have explored poten-tial mechanisms underlying the exercise–craving relation-ship. This section will discuss progress made and highlightopportunities for future research.
Affect hypotheses
Research has shown that exercise has a positive effect onaffect (Reed and Ones 2006), and it is possible that anincrease in positive affect could result in decreased desireto smoke. It has been shown that negative affect is associ-ated with increased withdrawal symptoms, desire to smoke,and relapse (Brandon 1994; Shiffman 2005). Two studiesfound that when positive affect was higher, cravings werelower (Everson et al. 2008; Elibero et al. 2011), but oneshowed that the changes in mood did not specifically medi-ate the exercise–craving relationship (Elibero et al. 2011),and the other did not examine affect as a mediating variablespecifically (Everson et al. 2008). Two other studies foundpositive effects of exercise on certain dimensions of affectimmediately post-exercise, but found no effect of exerciseon cravings (Arbour-Nicitopoulos et al. 2011; Williamset al. 2011).
It is worth noting that exercise intensity has a differ-ential effect on mood in abstaining smokers. For exam-ple, while Everson et al. (2008) showed similar effectsfor both moderate and vigorous exercise on cravings,participants reported adverse effects on mood and hap-piness during vigorous-intensity exercise. The adverseeffects returned to baseline immediately following vig-orous exercise, but if moderate and vigorous exerciseintensities have similar effects on cravings, then toavoid adverse effects on mood, perhaps moderate-intensity exercise, rather than vigorous-intensity exer-cise, should be prescribed.
In contrast to these findings, Bock et al. (1999) andHarper (Study 1, 2011) showed that a bout of vigorousexercise reduced negative affect and psychological with-drawal symptoms, respectively, in smokers undertaking anexercise-aided quit smoking programme. To explain thedifference between these studies, Everson et al. (2008) pro-posed that because participants in their study were abstain-ing for a relatively short duration for research purposes only,they were not motivated by an attempt to quit smoking, andtherefore potentially showed less tolerance towards the ad-verse effects of vigorous-intensity exercise than quittingsmokers. With this in mind, Everson et al. suggest that thereis potential to reframe the way smokers approach a bout ofvigorous exercise in this context, such that they focus on thebenefit of reduced cravings post-exercise, rather than theirfeelings during exercise.
However, exercise intensity was gradually increasedthroughout both smoking cessation programmes (Bocket al. 1999; Harper 2011, Study 1). This allowed the quittingsmokers to adapt to the exercise gradually, which is notpossible in an acute study (the participants in the Eversonet al. (2008) study had 1 min of familiarisation beforecompleting the exercise protocol). This potentially exposesthe pitfalls of these acute studies, whereby the effects do notnecessarily translate to the real world situation, which smok-ers attempting to quit experience. Moreover, Harper showedthat the magnitude of craving and withdrawal relief experi-enced following acute exercise sessions throughout theprogramme did not differ between those who successfullyquit smoking at the end of the study, and those who did not.
Although it is interesting to examine the effect of differ-ent exercise intensities on mood in this context, the primaryfocus of future research involving a measure of affect shouldbe to examine the mediating effect of mood on the exercise–craving relationship. As Elibero et al. (2011) did not findsuch a mediating effect, it would appear that the relationshipbetween mood and cravings in the context of exercise maybe more complex.
Biological hypotheses
There are a number of biological changes that occur duringsmoking and smoking cessation. In the previous review,Taylor et al. (2007) hypothesised that psychobiologicalchanges may mediate the changes in withdrawal symptomsassociated with exercise. They suggested that more studieswere needed to investigate changes in β-endorphins, opioids,and cortisol; however, few studies since have examined thepotential neurobiological mechanisms through which exercisemay act to reduce craving and other withdrawal symptoms.
Recent work by Janse Van Rensberg et al. (2009b, 2012)has begun to shed some light on the neurobiological pro-cesses underlying changes in cravings following exercise.Two studies were conducted to measure activation in spe-cific areas of the brain using fMRI (Janse Van Rensburget al. 2009b, 2012). fMRI scans were conducted whileparticipants were presented with a series of smoking-related images and neutral images. Subjective measures ofcravings were also taken. Janse Van Rensburg et al. (2009b,2012) concluded that reduction in cravings post-exercisemay be a result of the increased strain of exercise on thebrain’s information-processing capacity, reducing activationin areas of the brain associated with reward processing andvisuospatial attention, and concomitantly increasing activa-tion in the medial rostral prefrontal cortex, an area of thebrain associated with the ‘brain default mode’. This supportsthe hypothesis that exercise acts as a thought suppressant,shifting attention from cognitive to somatic thoughts(Avecado and Ekkekakis 2006).
12 Psychopharmacology (2012) 222:1–15
Two studies (Scerbo et al. 2010, Ho, PhD study) showedthat cortisol levels were higher post-exercise, but that differ-ences in cortisol concentration were not associated withchanges in desire to smoke in either study. Design featuresin both studies suggest further examination of cortisol as amechanism. First, the abstinence period in the Scerbo et al.(2010) study was short (3 h prior to assessment) comparedto most studies that used periods of 12–15 h overnightabstinence. The short abstinence period may have beeninsufficient to increase cigarette craving, thereby attenuatingthe mechanistic effect of salivary cortisol. The second study(Ho 2009) failed to find a significant effect of exercise onsmoking withdrawal symptoms and urges to smoke, poten-tially as a result of a lack of power, and thus the mediatingeffect of cortisol could not be tested.
To date, no other biological mediators of the exercise–craving relationship have been examined during temporarysmoking abstinence. As Taylor et al. proposed, futureresearch might consider the role of β-endorphins, opioids,and appetite suppression on the relationship between ciga-rette cravings and exercise. We propose that the role ofcatecholamines, heart rate variability, and nicotine metabo-lism should also be examined. With respect to catechol-amines, levels of adrenaline and noradrenaline have beenshown to increase with smoking (Laustiola et al. 1991), andsmoking cessation results in a decrease of both (Ward et al.1991). During single bouts of exercise, the concentration ofadrenaline and noradrenaline increases in proportion tothe intensity and duration of exercise (Richter and Sut-ton 1994). This increase in adrenaline and noradrenalinepost-exercise may explain the effect of exercise oncigarette cravings.
Studies have also shown that smoking causes reduc-tions in heart rate variability (HRV) (Lucini et al. 1996;Niedermaier et al. 1993). Following smoking cessation,HRV has been shown to subsequently increase 4 to6 weeks later (Stein et al. 1996). More research is requiredto examine (a) whether short-term smoking abstinence hasany immediate effect on HRV, (b) whether an acute bout ofexercise has any immediate effect on HRV, (c) whether thiseffect mediates the relationship between TWS and exercise,and (d) whether exercise can increase the rate at which HRVincreases post-cessation.
Finally, there is a dearth of research examining the effectof nicotine dependence on cravings and TWS. For instance,nicotine is metabolised to cotinine, and cotinine is metab-olised to 3-hydroxycotinine by the liver enzyme cytochromeP450 2A6. The rate of nicotine metabolism has been foundto predict smoking behaviour (Schnoll et al. 2009; Lermanet al. 2006). Future research is needed to examine whetherthe nicotine metabolite ratio influences cravings and TWSafter an acute bout of exercise during a temporary or actualquit attempt.
Cognitive hypotheses
It was initially hypothesised that exercise may influencecognitive demand in such a manner that it acts as a distrac-tion from smoking-related thoughts. However, two studiesidentified in the previous review (Daniel et al. 2006; Ussheret al. 2001) found no effect of distraction on cigarette crav-ings, and it was therefore surmised that the effects of exer-cise on cravings and withdrawal symptoms were not due todistraction (Taylor et al. 2007). Since then, two studies haveexamined the effect of exercise expectation on TWS andcravings (Daniel et al. 2007; Harper 2011, Study 2). Neitherstudy found an effect of expectation on TWS, but Harper didshow that those classified as high in exercise expectancy orexercise credibility had significantly greater reductions incravings post-exercise relative to those classified as low inexercise expectancy or credibility. Harper offers a number ofexplanations for this difference. First, the participants in theDaniel et al. study were only required to temporarily abstainfrom smoking, whereas Harper examined the effects of asingle bout of exercise on cravings 1 week into a quitattempt. Participants undergoing a quit attempt are moreinvested in the outcome than those temporarily abstainingfrom smoking, and there is evidence to suggest that the moreinvested in the treatment outcome a person is, the greater theinfluence of credibility and expectancy on treatment effects(Greenberg et al. 2006). Second, outcome expectancy wasmanipulated by Daniel and colleagues as positive, negative,or neutral, whereas Harper categorised participants based ontheir responses to the ECQ (Devilly and Borkovec 2000).Harper surmised that in order to experience an added reduc-tion in craving, one has to naturally believe that exercisecould result in such an effect, as opposed to being manipu-lated to believe in such an effect. Taken together, the find-ings from these studies suggest that expectancy andcredibility do not play a major role, but these variablescannot be completely discounted, and more research intothe effects of expectancy and credibility is warranted.
Conclusions
An acute bout of exercise reduces cigarette cravings andTWS. There are only small differences in the magnitude ofeffect for light, moderate, or vigorous exercise. The underly-ing mechanisms associated with the effect of exercise remainunclear. Translating these effects in temporarily abstinentsmokers to those trying to quit smoking is a priority.
Acknowledgments Mr. Roberts is supported by a University ofAuckland Doctoral Scholarship.
Conflict of interest The authors declare no conflict of interest.
Psychopharmacology (2012) 222:1–15 13
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