Quitting smoking without help is hard: Effects of motivation and other personality factors

Quitting smoking is hard, but that suggestion probably isn’t terribly exciting all on its own since most of our readers probably knew it already. Still, while we’ve talked about quitting smoking using nicotine replacement and medication, we haven’t really touched the subject of all those people out there who just decide to give quitting smoking a try one day without those patches, gums, or pills.

Since something like 95% of those who try their hand at quitting smoking relapse within one year, and most of these people try to quit unaided, I think this is an important topic to touch on. Fortunately, recent research conducted in the U.K. tried to assess the personality and cognitive aspects that end up predicting who will succeed, or fail, in their quit attempt.

The effects of expectation, motivation, and impulsivity when quitting smoking

Quite a bit of research has already shown that when smokers are trying to quit (so we’re talking early on during abstinence), their brains react differently to stimuli in the environment depending on the relationship between those stimuli and nicotine. Stimuli that aren’t associated with smoking (or some other form of nicotine intake) get less attention and show overall less activation of important brain circuits while nicotine associated cues light up the brain just as if nicotine was on board (even though participants were drug free at the time). Essentially, if a stimulus predicts getting a hit, the brain gets smokers to pay attention to it so that they can do whatever is necessary and get a little drug in. Throw in some of that reduced ability to control behavior that we talk about so much (like impulsivity), and which is common not only in smokers but in users of almost every other drug (heroin might be the exception) and you have a recipe for disaster, or at least for a good bit of smoking relapse. And yet if we want to fight the horrible health consequences of cigarettes, then quitting smoking has to be made easier, which nicotine replacement and medications like bupropion have done to some extent.

As part of this equation, knowing the specific predictors of early relapse in people who are quitting smoking may be useful so that professionals planning smoking interventions can do a better job of targeting the most important factors. The study recently published the journal Psychopharmacology tried to assess the relationship between the severity of smoking, the above-mentioned personality factors, and the success of the quitting attempt.

The cool thing about this study is that the 141 people who participated were assessed on a whole set of these cognitive tests twice – once after a smoking free night and a nicotine lozenge and another time after a smoking free night followed by a nicotine-free lozenge. While they couldn’t tell which was which, the procedure gave the researchers an assessment off how different participants’ reactions were with or without nicotine on board. Following the assessments participants were directed to begin their attempt at quitting smoking. While they were asked not to use nicotine replacement options or other medications, they were allowed to use any other resource available and were given a set of information pamphlets that explained expected side effects and likely difficulties during the quit attempt. They were then followed up after 1 week, 1 month, and 3 months. Quitting was identified as minimal smoking (less than 2 cigarettes per week) and was verified both by self report and cotinine testing. There was a small financial incentive to quitting, with people who relapsed after a week getting only £40 (about $60) and those who made it through month 3 getting £150 (about $250), though I’m pretty sure that if $200 was enough to make people quit we’d have just paid up already…

The first thing to note in the results was that 24% of the participants were still not smoking at the 33 month followup. This seems to be about on par with the usually low success rates at 1 year though I’m sure this research group will try to continue following these participants at least up to the 1 year mark and hopefully produce another paper.

The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interfering with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After the 1-week follow-up, at the 1 and 3 month assessment, the odds of quitting had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve been told you that the first week is the hardest and that once you make it through that the rest is a piece of cake. While this research doesn’t necessarily support that notion, since about 25% of the sample relapsed between each of the followups, it does seem to indicate that the reasons for relapse change after that first week.

It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking seems to be associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward.

Overall, these findings suggest that the cognitive function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can reduce relapse numbers at 1 week we can have a more gradual fall-off for the following month resulting in significantly higher quit rates.

Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medications like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

 

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The first thing to  note in the results was the 24% of the participants were still not smoking at the 33 month followup. This seems to be about on track for the normally low success rates at 1 year though I’m sure this group will try to follow these individuals up at that point and hopefully produce another paper. The overall most reliable predictor of who quit and who relapsed ended up being the level of nicotine dependence as measured by the participants’ pre-quit attempt cotinine levels and the number of cigarettes they smoked every day. Since cotinine assessments are less biased, it was the most predictive of all throughout the experiment (# of daily cigarettes was no longer predictive at 3 months). Interestingly, self reported impulsivity and smokers’ initial ratings of cravings for cigarettes didn’t end up predicting relapse at all, but those cognitive tests assessing the quitters’ reactions to nicotine associated cues told a pretty interesting story: It seems that early on during their quitting attempt smokers who had more general interference with their cognitive function relapsed sooner. These cognitive problems can be thought of as interruption with normal thinking by nicotine-related cues and maybe even more general interference with brain function. After that point, at the 1 and 3 month follow-ups, had more to do with baseline assessments of motor impulsivity as well as those initial cotinine levels assessing the degree of nicotine dependence.

The take-home: Quitting smoking is hard for different reasons in the first week and later on

If you’ve ever tried to quit you’ve heard someone telling you that the first week is the hardest and once you make it through that the rest is a piece of cake. Well, this research doesn’t really support that notion since about 25% of the sample relapsed between each of the followups, but it does seem to indicate that the reasons for relapse change after that first week. It seems that the first week may be difficult because of general cognitive interference by stimuli and cues that are nicotine associated. Those cues make it hard to pay attention to much else and they interfere with normal thinking and attention process, making sticking to the quit attempt difficult. After that point, successfully quitting smoking was associated more with the level of initial smoking and that damn motor impulsivity test. The finding that heavier smokers have a harder time quitting isn’t new and isn’t surprising, but the fact that cognitive effects and predictors of relapse change does suggest that the interventions likely to help smokers quit may need to be different during week 1 and afterward. Overall, these findings suggest that the brain function problems associated with quitting smoking (or smoking in general) may recover faster than do some of the other physiological factors associated with quitting since the initial levels of smoking continued to be highly predictive throughout the 3 month period of followup. Another explanation could be that initial smoking levels affected brain function in ways not assessed by these researchers.

Since so many smokers relapse within the first week (more than 50%), it seems to me that interventions that really focus on the cognitive interference and the extreme attention towards nicotine associated cues and stimuli would be helpful for those quitting smoking. Maybe if we can bring the relapse numbers down at 1 week we can have a more gradual fall-out for the following month resulting in significantly higher quit rates. Interestingly, NIDA and other research organizations are getting really interested in the use of technologies like virtual reality for help in addiction training. It seems that in this context, these sorts of treatments might be useful in helping early quitters train to avoid that cognitive interference. Additionally, medication like modafinil, and maybe even other ADHD medication could be used very early on for those quitting smoking to help recover some of their ability to control their attention thereby reducing the power that nicotine associated stimuli have over them. I guess we’ll have to wait and see as those who develop interventions start integrating this research. In the meantime, I’d love to hear from readers who have quit or tried to quit: Does this research seem to support your own experiences?

Citation:

Jane Powell, Lynne Dawkins, Robert West, John Powell and Alan Pickering (2010). Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors, Psychopharmacology.

The Creative Theory of Addiction Recovery

This is a guest post from Patrick Meninga of the Spiritual River website.

Since I first got clean and sober over 8 years ago, I have been creating a new life for myself. Talking about creation makes sense when I frame my recovery and how I have grown through the years, because it was always through deliberate change and deliberate action that I can look back and see how I have progressed in my personal growth.

Creation is a mindset in recovery….it is the attitude that is adopted by the winners in recovery. It doesn’t matter what exact program of recovery someone is working, be it the 12 step program or something else entirely. The winners in recovery, the people who are staying sober over the long run and really making growth in their recovery, they are the ones who are actively creating.

Creation goes beyond spiritual growth and takes more of an holistic approach. Essentially you have to treat the entire person for addiction, not just the spiritual malady. This is an important distinction because if you do not think in holistic terms then you might shut yourself off to possible avenues of growth in other areas of your life.

The creative mindset can help you to have a stronger recovery, by pushing you to grow in new ways. What then, are the critical steps to creating this new life for yourself? Let’s take a look:

1) Start with abstinence. Make this your number one priority and then start building on it. Early recovery is an awesome thing, because simple abstinence from drugs and alcohol can start opening up so many doors, so quickly. (This is why it’s called recovery, because you start recovering things you had previously lost: relationships, self esteem, perhaps a job, and so on). Make abstinence from drugs and alcohol the foundation of your recovery. Create a zero tolerance policy with yourself–that you will not use drugs or alcohol no matter what.

2) Use overwhelming force. I highly recommend that newcomers in recovery use this concept in order to make it through early recovery. The idea is to take whatever you think it is going to take in order for you to stay clean and sober and multiply it by ten. Examples:

* Don’t just go to treatment, go to long term treatment.

* Don’t just go to a meeting, go to a meeting every day (or several meetings a day).

* Don’t just go to a therapist, go to a therapist and actually act on the direction they give you.

You have to go above and beyond what you think is necessary in order to get through early recovery. So many people underestimate what it will take to stay clean, so you have to overcompensate in the other direction. Go big.

3) Focus on networking in early recovery. In early recovery, networking with others is of critical importance. We need help and support in order to recover. We also need to gain new knowledge.

4) Shift your focus as you progress to one of personal growth. Networking becomes less important at 5 years sober and even less so at 10 years. This does not mean that it is no longer a factor, it just becomes less important for you to network in order to stay clean and sober. As you progress, your own growth and personal development becomes a bigger part of how and why you stay clean. Therefore, you should motivate yourself to start growing holistically as you progress in your recovery. In other words, seek to grow in different areas of your life.

5) Focus on health. You should start treating yourself better in recovery as your self esteem repairs itself over the years. We abused ourselves for so long in addiction and that takes time to heal. Again, use a holistic approach. Seek to grow spiritually, but also start exercising, improve your diet, quit smoking, and so on. Look at your overall health and take care of your emotional well being as well.

This is important because one of your biggest insurances against relapse becomes your self esteem. If you feel good about yourself and value your life highly then it becomes less likely that you will relapse. Therefore, make it a point to take care of yourself in as many ways as possible. Live healthy in recovery and this help you in the fight against relapse.

6) There is only one hurdle in long term recovery: to overcome complacency. This is your only real hurdle as you move into long term recovery. You have to somehow be actively on guard against the subtle threat of relapse through becoming complacent. So how can you do that?

Push yourself to grow. Push yourself to learn new things. And here is one of the big shortcuts that will really help in overcoming complacency: continue to work with other recovering addicts and alcoholics on a regular basis. If you do this consistently and make a habit of it, then your recovery will be a lot stronger because of it.

If you start using some of these ideas and follow these strategies in your recovery, then you will notice after a while that you really have been creating a new life for yourself. It is not enough for us to simply get sober and sit around being passive all day….we need to get active, get involved, have a vision of some sort (a vision of helping others is particularly powerful). Take the idea of creative recovery and try to work it into your life, and you will start noticing the benefits right away.

Patrick Meninga is a recovering addict who writes at the Spiritual River about addiction recovery. Check him out if you are interested in learning more!

Global Commission on Drug Policy: Legalization, decriminalization, and the war on drugs

A commission made up of some big names, though not really any names of addiction or drug researchers I noticed, just released a report that’s making a lot of noise throughout every news channel including NPR (see here, and here for stories) and others (see CNN). They want the debate about the current state of drug regulation expanded, and since I’ve written on the issue before, I figured it’s time for another stab at this. Continue reading “Global Commission on Drug Policy: Legalization, decriminalization, and the war on drugs”

People, places, and things – How important are drug-related triggers for addiction relapse?

In cognitive behavioral therapy they’re a big part of the “Five W’s” = When, Where, Why, With, and What. In the various 12-step programs they’re simply referred to as “People, places, and things.” But no matter how you refer to them, drug-associated cues, or “triggers” as they are more commonly known, obviously play a big role in reminding addicted individuals about their drug-seeking behavior, and they are often enough to restart old behavior, even among those who have been abstinent for a while and especially when unprepared for their effect.

Different triggers to reactivate old behavior

Research on relapse (what researchers call reinstatement) has long shown that there are a number of things that can return a person, or an animal, to drug seeking after they have been abstinent for a while. Stress, small drug doses, and the presentation of triggers are all very capable of doing this, even after months of abstinence and likely even years. It’s probably not surprising that giving drugs to an abstinent person can make them want the drug again. In fact, I would venture to guess that most readers believe that this is the most powerful way to induce a relapse (assuming the initial exposure was out of a person’s control and doesn’t count).

Well, recent research suggests that in actuality, triggers, or those people, places, and things, might be more powerful or at least longer lasting relapse risks than even taking drugs!

Triggers, not drugs, are shown to be longest lasting relapse risk

Researchers in Japan trained mice to press a lever for meth, getting them to poke their nose into a hole 60 times for a total of 30 meth administration per three hour session. Every time they poked their nose in the right hole they got a shot of meth and a little light above their nose-poke hole went on (this will become the trigger in the end). Once they were doing this reliably the researchers took away the meth and the animals learned, within 10-20 days, that pressing the lever no longer got them a drug and reduced their number of presses to less than 15 presses per session.

After all this the researchers gave the mice an injection of meth 30 minutes before putting them back in the box – leading the mice to start pressing again for the drug even though in the previous session they has pretty much stopped pressing knowing that no drug was coming. Obviously, the drug injection caused the mice to relapse back into their drug seeking. But, as you can see from the figure below (on the left side, the right side shows that the mice didn’t poke their nose into a hole that did nothing as a control), this little trick only worked once, and the next time the mice were given a shot of meth before being put in the box (after once again being taken through extinction training teaching them that pressing the lever did nothing), they didn’t press the lever any more and just around not doing much.

For the following part of the study the researchers once again took the animals through extinction training (and once again the mice stopped pressing the lever for meth) and then in a following session reintroduced the little light that used to go on every time the mice originally got meth. Just like they did with the meth the animals immediately went back to pressing the lever like crazy, hoping that now that the light was back, so was their meth. Just like with the drug relapse experiment above, the researchers repeated this whole process over two months later, only this time, the little light managed to re-trigger the lever pressing again, unlike the one-trick-pony meth. Seeing this, the researchers went for broke and tried another run of this with the same animals, now following up five months after the last time the animals received meth when they pressed the lever. Again the little light got the animals to increase their pressing, only this time it was a little less impressive than the first two tries (but still significantly higher). All in all, the little light managed to restart the lever pressing by the mice three times and a full five month after the meth-relapse experiment had failed!!!

Conclusion, thoughts, and implications about triggers, relapse, and addiction

In a completely different article I’d written that researchers found a number of different patterns of relapse among alcoholics who went to rehab and that in fact, the vast majority of those who did relapse never went back to the kind of heavy drinking that characterized their earlier problem (see here for One is too many, a thousand not enough). While this research touches on a different aspect of relapse, it once again challenges our thinking about the crucial factors in relapse prevention among addicts. Everyone knows that triggers are important, but the fact that they are at least as powerful and apparently longer lasting dangers than even being re-exposed to the addictive drug is a novel one. Still, this isn’t very surprising given the very long-lasting impact of drugs of abuse (especially stimulants like crystal meth) on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. As you can see from the graph above, if a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.

Obviously preventing trigger-induced relapse should be a major strategy of addiction treatment and indeed, from CBT relapse prevention strategies to groundbreaking medications that have been shown to be effective for relapse rate reduction (like Vivitrol, Buprenorphine, Bupropion, and more), there is quite a bit of effort going exactly that way.

Citation:

Yijin Yan, Kiyofumi Yamada, Atsumi Nitta  and Toshitaka Nabeshima (2007). Transient drug-primed but persistent cue-induced reinstatement of extinguished methamphetamine-seeking behavior in mice. Behavioral Brain Research, 177, 261-268.

Is abstinence the only answer? Quality of life in addiction recovery.

Contributing author: Chelsea Crow

Abstinence should not be the only standard by which we measure success in addiction recovery.

There’s no doubt that for some addicts, full abstinence is necessary for recovery. Still, it would be hard to deny that even if they can’t stay completely clean, addicts who reduce their use substantially can see great improvement in their quality of life. I think that improvement shouldn’t be ignored.

I’ve been advocating for the use of other measures for success in addiction treatment for a while now, and a recent article gets us a step or so closer to having others consider it.

The study was conducted in New York City. All participants had a history of heavy illicit substance use for at least a year, and all self-reported abstinence for at least one month. The researchers then followed them for a period of two years, using a baseline interview at the beginning, after one year, and at the end. The interviews consisted of participants’ self-reported abstinence, Quality of Life , change in life satisfaction, as well as their commitment and motivation to abstinence.

Not surprisingly, the study found that those who reported greater life satisfaction at the baseline interview were likely to stay abstinent for longer. However, they also found that overall life satisfaction for participants remained high for most. What they didn’t look at was whether or not participants’ life satisfaction decreased with all levels of use or whether a severe relapse was necessary to cause such a reduction.

I think this should be one of our next explorations. I have a feeling that with reduced use comes greater life satisfaction and quality – even if the abstinence is not complete. I think that by beginning to explore that connection, we’ll be able to make much more refined discoveries about methods of treatment that can save lives. There’s no question that even reductions in use can allow the body, and brain, at least a partial recovery from the effects of heavy drug use.

I’ll keep you updated.

Citation:

Laudet, Alexandre B., Becker, Jeffrey B. & White, William L. (2009). Don’t Wanna Go Through That Madness No More: Quality of Life Satisfaction as Predictor of Sustained Remission from Illicit Drug Misuse. Substance Use & Misuse, 44 (2), 227-252.

Duchovny out of rehab

Well, it seems that David Duchovny completed his month log rehab stint for sex addiction. In this story, no further details are given regarding his reasons for entering treatment in the first place. But I’m sure we all wish him well, hoping that he’s been given some tools to deal with his problems.

As I noted in a previous posts about sex addiction, the problem can be difficult, sometimes even more so than drug addiction because sex is an activity the addict is still supposed to engage in, only in a “healthy” manner. Unlike the drug addict, abstinence is not a long term option for most sex addicts. I’ve talked before about whether abstinence needs to be the only option we talk about even when it comes to drug addiction ( think not), but when sex addiction is the topic, anything other than relatively short term abstinence in certainly not the ideal.

Again, I think there are strong parallels between sex addiction and substance abuse and hopefully, our ideas regarding proper recovery from both will evolve beyond the black and white state they are currently mired in.