Comparative Research on Tobacco Cessation Methods
By Frank Oden
As the leading preventable cause of death in the United States, cigarette smoking claims the lives of roughly 440,000 Americans each year. More than 8.6 million people in the United States have at least one serious illness caused by smoking, and smoking will eventually result in death or disability for half of all continuing smokers (US Department of Health and Human Services 1990). Due in part to increased public awareness of the associations between smoking and serious health risks, as many as 80% of the estimated 44.5 million Americans who currently smoke express the desire to stop (USDH 1990). For most smokers, however, it is not simply a matter of wanting to stop. An acquired tolerance for and physical dependence on the psychoactive substance nicotine is the primary physiological component of the addiction and the main cause of relapse within the first two weeks of quitting. But it is the deeply entrenched behavior patterns (including habitual tendencies toward failure and loss of motivation to quit) that become more persistent over time and are the main cause of relapse in the months or even years after a person has successfully defeated the nicotine dependence.
A great deal of research has gone into the efficacy of various interventions available to smokers who want to quit. Most of the applied research has been conducted in pharmaceutical studies, which address only the nicotine dependence feature of smoking. Comparatively little applied research has been conducted with regard to behavioral and motivational interventions, and it is the general practice of medical clinicians and public smoking cessation programs to offer only general education about the health risks of smoking and a recommendation of nicotine replacement therapy or prescription anti- depressants . (Shwartz 1992)
While the pharmacological interventions have been shown more effective than no assistance at all, this limited approach is necessarily less effective than the results that could be achieved with a multi-faceted comprehensive protocol that also includes long-term behavior modification and positive motivational techniques (Thorndike 2006). The current emphasis on pharmacology to the exclusion of other methods may even represent a disservice to smokers. Nicotine replacement alone cannot cause an unmotivated smoker to quit, but properly motivated smokers can and often do quit easily without drugs of any kind.
THE NATURE OF SMOKING
The smoking habit, or what is broadly referred to as an addiction to cigarettes is actually comprised of two specific components – physical dependence on nicotine, and the behavior patterns which have arisen as a result of that dependence (Okuyemi 2006). These two components are not equal contributors to the persistence of smoking as a chronically relapsing addiction, nor are they equal in terms of their impact on a smoker who is attempting to quit.
Physical Dependence on Nicotine. Nicotine is the psychoactive drug in cigarette smoke. It is classified as a minor stimulant similar to caffeine, and produces increases in heart rate, blood pressure, adrenaline release and gastric activity. Sixty milligrams of nicotine is a lethal dose in humans but smokers generally self-administer only about one milligram of nicotine per cigarette smoked. At this dosage, the smoker experiences only the early warning signs of toxicity – a brief dissociative lightheadedness and loss of equilibrium which are psychoactive effects resulting from the action of nicotine on acetylcholine receptor sites in the brain (Julien 2001). Most novice smokers or tobacco chewers experience these symptoms as unpleasant and do not pursue tobacco use as a desirable activity. But many others interpret this mild toxicity as a subjective sense of euphoria, or “buzz,” and continue using tobacco to re-experience the effect.
As a result of the body’s natural tendency to protect itself, the more frequently a person uses nicotine (or any drug), the more effectively the body defends against the toxic effects. By the time a person has become a regular smoker, that person’s brain has established a very effective tolerance for nicotine, and the smoker no longer experiences the subjective effects of toxicity, except after a period of abstinence from the drug. The length of abstinence necessary to lose the tolerance for nicotine can vary from hours to days or even weeks depending on an individual smoker’s physiology and the level of previous nicotine dependence. The physical process of losing the tolerance for a drug is referred to as “withdrawal” and is characterized by symptoms that are equal and opposite to the physical and subjective effects of the drug. (Julien)
In the case of a mild and short-acting stimulant such as nicotine, the physical effects of withdrawal are short-term symptoms of reduced energy and mental focus. Because nicotine has a very short half-life in the body, smokers will smoke to alleviate signs of withdrawal if they are noticed or, more often, to anticipate and prevent the onset of withdrawal. But in most regular smokers, the self-administration of nicotine intake is steady and easily available enough to reliably pre-empt any onset of noticeable withdrawal symptoms. Most of the smoking done by a heavy smoker goes above and beyond the need to maintain nicotine levels in the body, most of the cigarettes are smoked in response to an entirely different mechanism.
Drug-Reinforced Associative Learning. While the pharmacological features of substance dependence are readily observed in the processes of tolerance and withdrawal, the current view of drug addiction is more often defined in terms of drug-seeking behaviors. The capacity of psychoactive drugs to serve as positive reinforcers is well documented in the context of associative learning and operant conditioning (Stolerman 1992). Relief from withdrawal symptoms is only one type of reinforcing consequence of drug use. Other types of reinforcing factors may involve social context, positive affect, self-image, or functional enhancement (Bevins 2004).
Specific to nicotine and the use of cigarettes, smokers form very strong drug-reinforced associations between smoking and other environmental stimuli such as places, people, activities, internal feelings, etc. All smokers have reinforced idiosyncratic smoking behaviors that become personal rituals, but most also share a wide range of common associations such as smoking to relax or relieve stress, smoking while driving, smoking after meals, smoking on work breaks, smoking with coffee and with alcohol, smoking with another smoker.
In each case, the drug-seeking behavior of smoking a cigarette to put nicotine in the bloodstream has been repeatedly paired with a range of particular environmental conditions. With enough drug-reinforced pairings of two such events, the environmental stimulus acquires the capacity to function as a discriminative cue that now elicits the behavior (Powell 2005). A smoker lights a cigarette in response to a particular cue because he always does so in response to that cue, regardless of whether he consciously wants to smoke or even realizes that he’s doing so.
What Matters Most? Nicotine dependence is the initiating factor of a smoking habit, but behavioral associations lead to much more smoking than substance dependence requires. Nicotine dependence is a finite quantity which does not completely explain smoking behavior. When given nicotine-free cigarettes, most smokers will complain that they are less satisfying, but will continue to smoke anyway (Cummings 1982). Drug-reinforced behaviors will continue to increase in range and grow stronger over the life-span of a smoker, perpetuating the frequency of smoking far beyond the point of deriving any “pleasure” from the drug.
THE NATURE OF SMOKING CESSATION
Physical Withdrawal from Nicotine. The physical symptoms of nicotine withdrawal are mild and short in duration. Temporary loss of energy and occasional difficulty with mental concentration are the only physiological symptoms which can be directly attributed to the process of losing tolerance to nicotine and restoring sensitivity to the internal production of acetylcholine. Other symptoms and subjective effects which are sometimes described by abstinent smokers, such as irritability or tension are not direct physical effects of the psychopharmacology of nicotine. These subjective effects are more often related to a person’s attitude about not smoking cigarettes, or may be symptoms of caffeine toxicity which were previously masked and mitigated by nicotine use (Julien 2001).
Because nicotine has a short half-life in the body, it is completely gone from the system within 72 hours, at which point the physical symptoms of withdrawal can be expected to peak and begin to subside. Considering the mildness of the actual symptoms and the rapid course of detoxification, it could not be considered a severe physical illness or incapacity. It is very unlikely that medication would be prescribed for these symptoms if they were the result of a common virus. There relevance and impact of nicotine dependence on the process of quitting smoking is minor, temporary and successfully negotiated by most people who attempt to quit smoking “Cold Turkey.” About 10% of smokers experience no physical withdrawal symptoms at all (Cummings 1982). The only necessary component to quitting, with regard to nicotine, is that a person must stop taking nicotine at some point and allow the process to run its course.
Extinction Phase of Learned Behaviors. In a quit-smoking attempt, the persistence of drug-reinforced learning is much more problematic than the persistence of the drug itself. The ability to re-program drug-reinforced behaviors is a necessary factor for success, and it can only be fully accomplished in the presence of the situational trigger and the absence of the reinforcing drug. It would be very difficult for an abstinent smoker to specifically identify the subtle internal sensations of lacking nicotine, but it is overwhelmingly noticeable what is wrong when he’s suddenly prevented from doing something that he has trained himself to do automatically and without fail dozens of times per day (Anczak 2003).
In order to effectively quit smoking, regardless of nicotine processes, a smoker must accomplish the extinction of a wide range of habitual drug-seeking behaviors that have previously been reinforced with nicotine. This can be done by concerted effort in a cue-by-cue behavior modification process of noting each relevant cue and learning to specifically withhold the drug in that situation, or it may be accomplished more simply and globally with a “cold turkey” mindset, where the sole focus is to eliminate all nicotine and allow the behaviors to extinguish themselves automatically whether the individual cues are catalogued or not.
In either case, the effectiveness of any behavioral extinction process will be directly proportional to the certainty that no drug reinforcement can be obtained. A relevant feature in the extinction process of any learned behavior is that “extinction bursts” typically occur in the early stages, defined as a temporary increase in the intensity of an attempted response when a reinforcer is initially removed (Powell 2005). A familiar example is the temper-tantrum as thrown by a small child. If a parent never reinforces a child’s tantrum by delivering the desired toy, candy or attention, the tantrum behavior will rapidly and permanently cease. But if a child’s tantrums are sometimes ignored and sometimes reinforced depending on severity or context, the behavior will continue and intensify and become much more difficult to extinguish in the future (Author, personal experience, 1984-88!). Because smokers who are trying to quit are responsible for establishing their own criteria for the contextual significance of cues and the severity of cravings (tantrums?), most of those who fail will fail repeatedly. A person who “cheats” in response to an extinction burst effectively provides a condition of drug reinforcement for failing to achieve a goal. In fact, the longer a person remains abstinent before failing, the more likely he is to re-experience the dramatic subjective effects of “the buzz.” Because this reinforcement leads to an increase in failure-oriented behavior, there is a 95% probability that one cigarette will lead a former smoker back to the habit. This is the basis for the widely publicized fact that most smokers who want to quit will try and fail several times before they eventually succeed. (USDH 2006)
What Matters Most? In any quit attempt, the elimination of physical dependence on nicotine will happen naturally, automatically and rapidly within the first days or weeks of abstinence. The symptoms are mild and would not warrant medication in other contexts. Smokers do not typically interpret the actual physical symptoms as a motivation for relapse. More often, relapse occurs in response to contextual cues for smoking behavior such as stress or alcohol use. Because smokers end up creating associations with so many different environmental and situational cues, the habitual impulse to smoke cigarettes in response to everyday ordinary triggers is noticeable immediately upon abstinence. Infrequent but uniquely compelling triggers associated with major stressors such as intoxication, job loss, auto accidents or relationship troubles can retain their power as discriminative stimuli for drug use long after the user has successfully eliminated dependence on nicotine and defeated the ordinary day-to-day impulses. While nicotine dependence rapidly ceases to be a factor in abstention from smoking, the impact of drug-reinforced associative learning has the capacity to influence future behavior at any time throughout the rest of a former smoker’s life.
THE NATURE OF SMOKING INTERVENTIONS
Pharmacological Intervention. The intervention method that is most widely advertised, widely applied, heavily funded and strongly recommended by medical sources is the pharmacological approach to smoking cessation, which may be considered in two categories: Nicotine Replacement Therapies (NRT) and Non-NRT medications.
NRT options are designed to help a smoker gradually reduce the physical dependence on nicotine so as to minimize physical withdrawal while abruptly stopping the intake of the toxic smoke. Slow transdermal release of nicotine through adhesive patches, or intermittent oral doses by chewing nicotine gum, are aimed at alleviating withdrawal in heavy smokers who demonstrate a high nicotine dependence. (Cofta-Woerpel 2006). If properly managed and combined with behavior modification strategies, NRT are shown to be very effective in aiding a cessation attempt (Kenford, et al. 1994), but nicotine replacement in itself does not address habitual smoking behaviors. Also, NRT’s such as nicotine gum may be misused or abused by some smokers and may cause unpleasant side effects such as nausea, headache, insomnia, abnormal dreams and changes in taste perception (Sees 1990).
Non-NRT pharmacotherapy primarily involves prescription of the antidepressant buproprion hydrochloride (brand names Zyban, Wellbutrin). Buproprion is believed to address withdrawal symptoms by increasing dopamine activity in “pleasure centers” of the brain, and also increasing norepinephrine in the frontal cortex to enhance alertness, concentration and memory (Anczak & Nogler 2003). Also in the non-NRT category is the newly approved drug varenicline (brand name Chantix) which act as a partial agonist at nicotinic ACH receptor sites producing a mild nicotine-like stimulation, partially offsetting withdrawal and partially blocking the effects of nicotine intake. (Pfizer)
Pharmacological interventions are capable of helping smokers acheive cessation rates of up to 35%, which is well above quit rates for placebo and control groups. However, up to 30% or more of smokers may reject or discontinue use of NRT and other pharmacological interventions because of unpleasant side effects including nausea, altered dream patterns, constipation and gastric distress (Kenford 1994).
Another factor which negatively impacts the utility of a pharmacological approach is that an uneducated end-user may have false impressions that the pills or patches have intrinsically curative effects that can stop a person from smoking. Applying a nicotine patch to the arm has no effect other than providing a steady dosage of nicotine, it can ease whatever withdrawal symptoms may be present, but it will not spontaneously cause involuntary abstinence.
Psychological Intervention. Psychological cessation methods are based on principles of behavioral psychology including aversive conditioning, stimulus control, contingency management and motivational approaches.
In aversion therapy, smoking may be paired with aversive stimuli such as nauseating imagery or even electrical shock to create negative associations intended to diminish or eliminate the urge to smoke. This type of treatment can be very effective but up to 50% of smokers who begin shock therapy will drop out before the treatment is completed (Cummings 1982). Another form of aversion therapy is rapid smoking, in which a smoker is required to smoke a great deal more than normal in a short amount of time to produce the intrinsically negative effects of nicotine toxicity, but this method also produces dangerously high carbon monoxide levels and may be life threatening in itself.
Stimulus control is a process in which smokers identify discriminative stimuli (triggers) that have become associated with their urges to smoke (driving, finishing meals, work breaks, etc) and make specific efforts to modify the presentation and/or outcomes of these particular situations. Whether undertaken consciously or not, this process of cue exposure and response prevention is necessarily involved in any successful quit attempt. Education in the basic principles and focused attention on the process can help to ease and expedite this necessary extinction phase of learned behaviors.
Contingency management is based on eliciting a pre-commitment response from the smoker, such as an interpersonal contract that involves meaningful rewards for successful abstinence and a personally significant penalty if the smoker relapses. Nonsmoking friends and family members often make this kind of contract or wager with smokers who are trying to quit, the value of this technique will of course vary by individual, depending on the nature of the relationship and the specific consequences.
Behavioral techniques such as stimulus control and contingency management have no intrinsic risks or drawbacks, although they require a level of commitment and a degree of diligence from the smoker to carry out pre-planned strategies on an ongoing basis. Considering that some level of commitment and diligence are in any case requisite for a successful quit attempt, some form of cognitive-behavioral therapy is generally recommended by all sources as worthwhile on its own merits, and also as a valuable adjunct to any prescribed pharmacotherapy.
Motivational Intervention. There are many types of motivational resources for smokers trying to quit; most bookstores have a wide selection of self-help books on the topic. One of the most popular is “The Easy Way to Stop Smoking” by Alan Carr, which guides a smoker through a gradual process of quitting over the time-course of working through the chapters of the book. A variety of behavior modification strategies are outlined, combined with education and motivational imagery to help a smoker focus on the positive rewards and self-esteem of being a nonsmoker, rather than the counterproductive negative affect of feeling deprived of cigarettes (Carr 1985). This type of primer on nonsmoking skills and motivation to positive attitude is similar to most other self-help books on the subject. Motivational reading can be very helpful for a smoker who wants to learn about effective mindset as well as effective techniques. Of course, the inherent drawback to a solitary approach that relies only on written materials for support is that the smoker must demonstrate the initiative to take action and not simply read about it
Motivational support can be provided interpersonally through counseling, where cognitive motivational therapy can assist smokers in developing practical coping skills and the capacity to persist despite attitudinal setbacks (Thorndike 2006). Motivational support and collaboration is also available through classes, lectures and support groups, either in person or remotely through internet resources such as “WhyQuit,” a free online library and open forum of community support for people who are quitting smoking “Cold Turkey” (whyquit.com).
Individual and group motivation is also possible through the use of hypnosis. Many people erroneously believe that hypnosis offers the externally enforced removal of a smoker’s ability to smoke (many unscrupulous hypnotists capitalize on this popular misconception, this type of practice amounts to little more than faith healing). But the practical value of applied hypnosis is in the use of suggestion, focused attention and therapeutic relationship to amplify and assist an individual’s innate ability to alter their own perception, emotion and/or behavior (Covino & Bottari 2001). Hypnosis can offer a powerfully motivating technique towards greater self-efficacy by altering an individuals “top-down” processing of external stimuli (Blakeslee 2005) and towards greater behavioral persistence by aiding in the creation of a self image of pre-determined accomplishment (Houser-Marko 2006).
Regardless of the source or nature of a smoker’s motivation to quit smoking, it is reasonable to say that no attempt to abstain can succeed without it. And yet motivation alone can succeed in the absence of any or all other specific intervention techniques.
What Matters Most? The smoking habit is comprised of physical and psychological components. It is clear that the psychological / behavioral / motivational components of drug addiction are the most characteristic features of the basic nature of smoking, have the most impact on efforts to quit smoking, and are the most important feature to address in any intervention attempt. The primary point of contact for most smokers on the subject of smoke cessation is the smoker’s doctor or other medical clinician, and there are widespread efforts currently in place to ensure that all medical professionals inquire about and offer treatment for a patient’s tobacco use in all medical contexts. The current standard for intervention is brief advice about the health risks of smoking (aversion is perhaps the least effective motivational tool) followed by recommendation of NRT and/or a prescription for antidepressants (Okuyemi 2006). This approach is not consistent with the nature of smoking and smoke cessation as summarized below:
Pharmacology can help, but is the least necessary component of intervention
It cannot succeed without motivation and behavior modification
Nicotine replacement is drug maintenance, not recovery
Nicotine withdrawal is mild and temporary
NRT does not enforce behavior modification
NRT does not replace or create motivation
Behavior Modification is necessary, whether cognitive or automatic
It may be aided by pharmacology, but can succeed without it
It does not replace, but can enhance motivation
Motivation is the most useful feature to address in an intervention
It may be aided by pharmacology, but can succeed without it
It can produce automatic Behavior Modification
It is the only intervention that can succeed on its own
If new standards for tobacco intervention were based on these criteria, the outcome would be less defined by addressing only the physical dependence on nicotine and health practitioners might convey a more helpful and effectively prioritized approach to smoking cessation. While many people have successfully quit smoking by supporting their intrinsic motivation with pharmacological and/or behavioral assistance, every person who has ever successfully quit smoking has ultimately done it the same way, the only way that it can be done. At one specific moment in time, they were motivated to extinguish their final cigarette and they sustained the lifelong motivation to never light another one.
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