The Effects of Acceptance and Commitment Therapy on Man Smokers’ Comorbid Depression and Anxiety Symptoms and Smoking Cessation: A Randomized Controlled Trial

Document Type : Original Article(s)


1 MSc Student, Department of Clinical Psychology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran

2 Associate Professor, Department of Clinical Psychology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran

3 Assistant Professor, Department of Community Medicine, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran

4 Psychiatrist, Associate Professor, Department of Psychiatry, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran


Background: Besides physical problems, cigarette smoking is associated with a high prevalence of comorbid depression and anxiety symptoms. One of the reasons behind high post-cessation smoking lapse and relapse rates is inattentiveness to these symptoms during the process of cessation. The aim of this study was to examine the effects of acceptance and commitment therapy (ACT) on male smokers’ comorbid depression and anxiety symptoms and smoking cessation.Methods: This two-group pre-test-post-test randomized controlled trial was done on a random sample of seventy male smokers. Participants were randomly and evenly allocated to an intervention and a control group. Patients in these groups received either acceptance or commitment therapy or routine psychological counseling services include cognitive behavior therapy, respectively. Study data were collected through a demographic questionnaire, the Structural Clinical Interview (SCI) for Diagnostic and Statistical Manual of Mental Disorders-4th edition (DSM-IV) disorders, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Micro Smokerlyzer carbon monoxide monitor.The SPSS software was employed to analyze the data.Findings: After the intervention, depression and anxiety scores and smoking cessation rate in the intervention group were respectively lower and higher than the control group (P < 0.050).Conclusion: ACT can significantly improve comorbid depression and anxiety symptoms and smoking cessation rate. Thus, it can be used to simultaneously manage depression, anxiety, and cigarette smoking.


  1. PDQ Screening and Prevention Editorial Board. Cigarette smoking: Health risks and how to quit (PDQ®) [Online]. [cited 2017 Apr 27]; Available from: URL:
  2. World Health Organization. The tobacco atlas. 1st ed. Geneva, Switzerland: WHO; 2002.
  3. Azizi F, Rahmani M, Emami H, Mirmiran P, Hajipour R, Madjid M, et al. Cardiovascular risk factors in an Iranian urban population: Tehran lipid and glucose study (phase 1). Soz Praventivmed 2002; 47(6): 408-26.
  4. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer-Lindgren L, Thomson B, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311(2): 183-92.
  5. McCracken L. Mindfulness and acceptance in behavioral medicine: Current theory and practice. Oakland, CA: New Harbinger Publications; 2011.
  6. Hatsukami DK, Stead LF, Gupta PC. Tobacco addiction. Lancet 2008; 371(9629): 2027-38.
  7. Ekpu VU, Brown AK. The economic impact of smoking and of reducing smoking prevalence: Review of evidence. Tob Use Insights 2015; 8: 1-35.
  8. Sotiriou I, Chalkiadaki K, Nikolaidis C, Sidiropoulou K, Chatzaki E. Pharmacotherapy in smoking cessation: Corticotropin releasing factor receptors as emerging intervention targets. Neuropeptides 2017; 63: 49-57.
  9. Aubin HJ, Luquiens A, Berlin I. Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice. Br J Clin Pharmacol 2014; 77(2): 324-36.
  10. Gifford EV, Kohlenberg BS, Hayes SC, Pierson HM, Piasecki MP, Antonuccio DO, et al. Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation. Behav Ther 2011; 42(4): 700-15.
  11. Killen JD, Fortmann SP, Schatzberg AF, Arredondo C, Murphy G, Hayward C, et al. Extended cognitive behavior therapy for cigarette smoking cessation. Addiction 2008; 103(8): 1381-90.
  12. Roberts NJ, Kerr SM, Smith SM. Behavioral interventions associated with smoking cessation in the treatment of tobacco use. Health Serv Insights 2013; 6: 79-85.
  13. Midlarsky E, Pirutinsky S, Cohen F. Religion, ethnicity, and attitudes toward psychotherapy. J Relig Health 2012; 51(2): 498-506.
  14. Sapp M. Basic psychological measurement, research designs, and statistics without math. Springfield, IL: Charles C. Thomas Publisher; 2006.
  15. Kawai A, Kano M, Sato T. Motivational interviewing and cognitive behavior therapy for smoking cessation. Nihon Rinsho 2013; 71(3): 493-8. [In Japanese].
  16. Nakamura M, Oshima A, Ohkura M, Arteaga C, Suwa K. Predictors of lapse and relapse to smoking in successful quitters in a varenicline post hoc analysis in Japanese smokers. Clin Ther 2014; 36(6): 918-27.
  17. Kenford SL, Fiore MC, Jorenby DE, Smith SS, Wetter D, Baker TB. Predicting smoking cessation. Who will quit with and without the nicotine patch. JAMA 1994; 271(8): 589-94.
  18. Zvolensky MJ, Gibson LE, Vujanovic AA, Gregor K, Bernstein A, Kahler C, et al. Impact of posttraumatic stress disorder on early smoking lapse and relapse during a self-guided quit attempt among community-recruited daily smokers. Nicotine Tob Res 2008; 10(8): 1415-27.
  19. Kapson HS, Haaga DA. Depression vulnerability moderates the effects of cognitive behavior therapy in a randomized controlled trial for smoking cessation. Behav Ther 2010; 41(4): 447-60.
  20. Fluharty M, Taylor AE, Grabski M, Munafo MR. The association of cigarette smoking with depression and anxiety: A systematic review. Nicotine Tob Res 2017; 19(1): 3-13.
  21. Shiffman S, Paty JA, Gnys M, Kassel JA, Hickcox M. First lapses to smoking: within-subjects analysis of real-time reports. J Consult Clin Psychol 1996; 64(2): 366-79.
  22. Capron DW, Allan NP, Norr AM, Zvolensky MJ, Schmidt NB. The effect of successful and unsuccessful smoking cessation on short-term anxiety, depression, and suicidality. Addict Behav 2014; 39(4): 782-8.
  23. Hofmann SG. The Wiley handbook of cognitive behavioral therapy. Hoboken, NJ: Wiley; 2013.
  24. Bland P. Smoking cessation improves anxiety depression. Practitioner 2014; 258(1769): 5.
  25. Correa-Fernandez V, Ji L, Castro Y, Heppner WL, Vidrine JI, Costello TJ, et al. Mediators of the association of major depressive syndrome and anxiety syndrome with postpartum smoking relapse. J Consult Clin Psychol 2012; 80(4): 636-48.
  26. Guichenez P, Guillaumin C. Cognitive behavior therapy in smoking cessation. Rev Mal Respir 2008; 25(10): 1351-2. [In French].
  27. Patten CA, Martin JE, Myers MG, Calfas KJ, Williams CD. Effectiveness of cognitive-behavioral therapy for smokers with histories of alcohol dependence and depression. J Stud Alcohol 1998; 59(3): 327-35.
  28. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000; 68(4): 615-23.
  29. Cayoun BA. Mindfulness-integrated CBT: Principles and practice. Hoboken, NJ: Wiley; 2011.
  30. Lau MA, McMain SF. Integrating mindfulness meditation with cognitive and behavioural therapies: the challenge of combining acceptance- and change-based strategies. Can J Psychiatry 2005; 50(13): 863-9.
  31. Hayes SC, Strosahl KD. A Practical guide to acceptance and commitment therapy. New York, NY: Springer; 2004.
  32. Saedy M, Kooshki S, Jamali FM, Emamipour S, Rezaei AA. Effectiveness of acceptance-commitment therapy on anxiety and depression among patients on methadone treatment: A pilot study. Iran J Psychiatry Behav Sci 2015; 9(1): e222.
  33. Davison TE, Eppingstall B, Runci S, O'Connor DW. A pilot trial of acceptance and commitment therapy for symptoms of depression and anxiety in older adults residing in long-term care facilities. Aging Ment Health 2017; 21(7): 766-73.
  34. Bricker JB, Copeland W, Mull KE, Zeng EY, Watson NL, Akioka KJ, et al. Single-arm trial of the second version of an acceptance and commitment therapy smartphone application for smoking cessation. Drug Alcohol Depend 2017; 170: 37-42.
  35. Bricker JB, Mann SL, Marek PM, Liu J, Peterson AV. Telephone-delivered acceptance and commitment therapy for adult smoking cessation: a feasibility study. Nicotine Tob Res 2010; 12(4): 454-8.
  36. Mak YW, Lee PH, Loke AY. Predictors of participation in a telephone-based acceptance and commitment therapy for smoking cessation study. BMC Public Health 2015; 15: 1288.
  37. Mak YW, Loke AY. The acceptance and commitment therapy for smoking cessation in the primary health care setting: A study protocol. BMC Public Health 2015; 15: 105.
  38. Kelly MM, Sido H, Forsyth JP, Ziedonis DM, Kalman D, Cooney JL. Acceptance and commitment therapy smoking cessation treatment for veterans with posttraumatic stress disorder: a pilot study. J Dual Diagn 2015; 11(1): 50-5.
  39. Sharifi V, Asadi SM, Mohammadi MR, Amini H, Kaviani H, Semnani Y, et al. Structured clinical interview for DSM-IV (SCID): Persian translation and cultural adaptation. Iran J Psychiatry 2007; 2(1): 46-8.
  40. Wetherell JL, Gatz M. The Beck Anxiety Inventory in older adults with generalized anxiety disorder. J Psychopathol Behav Assess 2005; 27(1): 17-24.
  41. Azkhosh M. Application of mental assessments and clinical diagnostics. 3rd ed. Tehran, Iran: Ravan Publications; 2008. [In Persian].
  42. Kaviani H, Mousavi AS. Psychometric properties of the Persian version of Beck Anxiety Inventory (BAI). Tehran Univ Med J 2008; 66 (2): 136-40. [In Persian].
  43. Jarvis MJ, Russell MA, Saloojee Y. Expired air carbon monoxide: a simple breath test of tobacco smoke intake. Br Med J 1980; 281(6238): 484-5.
  44. Jones HA, Heffner JL, Mercer L, Wyszynski CM, Vilardaga R, Bricker JB. Web-based acceptance and commitment therapy smoking cessation treatment for smokers with depressive symptoms. J Dual Diagn 2015; 11(1): 56-62.
  45. Vinci C, Spears CA, Peltier MR, Copeland AL. Facets of mindfulness mediate the relationship between depressive symptoms and smoking behavior. Mindfulness (NY) 2016; 7(6): 1408-15.
  46. Rogojanski J, Vettese LC, Antony MM. Coping with cigarette cravings: Comparison of suppression versus mindfulness-based strategies. Mindfulness 2011; 2(1): 14-26.
  47. Eifert GH, Forsyth JP. Acceptance and commitment therapy for anxiety disorders: A practitioner's treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger Publications; 2005.
  48. Blackledge JT, Ciarrochi J, Deane FP. Acceptance and commitment therapy: Contemporary theory research and practice. Bowen Hills, Australia: Australian Academic Press; 2009.
  49. De Groot F, Morrens M, Dom G. Acceptance and commitment therapy (ACT) and addiction: a literature review. Tijdschr Psychiatr 2014; 56(9): 577-85. [In Dutch].