We believe that how one reacts to the discomfort of nicotine withdrawal and quitting smoking is a promising avenue of investigation and may have important treatment implications. We have proposed that the inability to tolerate the distress of nicotine withdrawal and associated negative affect is a key factor in early smoking lapse and subsequent relapse. The results of our early development of a distress tolerance treatment which incorporates graded exposure and ACT-based distress tolerance skills are encouraging and hold the promise of an effective distress tolerance treatment for not only at-risk smokers with a history of early lapse but for the adult cigarette smoking population in general, given the universal impact of distress and negative affective factors upon successful smoking cessation. The objective of this Stage II, randomized controlled trial (RCT) is to evaluate the efficacy of an integrative, distress tolerance (DT) protocol for the treatment of nicotine dependence versus a standard smoking cessation (ST) comparison intervention, with both treatments including transdermal nicotine patch. A total of 202 adult cigarette smokers will be randomly assigned to one of the two treatment conditions. Treatments will consist of six individual and nine group sessions over nine weeks, and the treatments will be equated for participant and therapist contact time. Participants will be followed over 52 weeks, and self- reported abstinence will be verified by carbon monoxide and saliva cotinine. We will also examine the hypothesis that changes in negative affective reactivity prior to and during initial smoking cessation will mediate the effects of DT treatment. We expect that as a result of this project, we will have developed a well-specified and novel integrative, distress tolerance treatment for adult cigarette smokers. Subsequent efforts will focus on the dissemination of this treatment approach to community-friendly settings and on the adaptation of this approach for less intensive intervention treatment modalities, such as telephone and other briefer interventions. This application is innovative in its effort to target specifically the distress and negative emotional reaction that typically accompany attempts at smoking cessation and have been shown to be so influential in determining smoking cessation outcomes. If successful, the development and subsequent dissemination of these treatment approaches will have important clinical and public health significance in decreasing the overall prevalence of cigarette smoking, thereby reducing smoking-related morbidity and mortality. PUBLIC HEALTH RELEVANCE: We expect that as a result of this project, we will have developed a well-specified and novel integrative, distress tolerance treatment for adult cigarette smokers. Subsequent efforts will focus on the dissemination of this treatment approach to community-friendly settings and on the adaptation of this approach for less intensive intervention treatment modalities, such as telephone and other briefer interventions. This application is innovative in its effort to target specifically the distress and negative emotional reaction that typically accompany attempts at smoking cessation and have been shown to be so influential in determining smoking cessation outcomes. If successful, the development and subsequent dissemination of these treatment approaches will have important clinical and public health significance in decreasing the overall prevalence of cigarette smoking, thereby reducing smoking-related morbidity and mortality.