Convincing yourself to quit smoking – The influence of personal beliefs on smoking

no-smoking1A study published in Addictive Behaviors showed that thinking actively about quitting smoking cigarettes allows people to smoke less!!!

In the experiment, participants from one group of smokers were asked to think about reasons to quit smoking and write them down on a piece of paper. Participants from a second group of smokers were asked to read pre-written anti-smoking arguments.

Both groups of participants were then asked to wait up to 30 minutes while the experimenter prepared a task unrelated to the actual experiment. Individuals who generated their own arguments against smoking abstained from smoking cigarettes longer than those who read pre-written anti-smoking arguments.

The results of this experiment suggest that self-generated information has a greater influence on smoking behavior (at least in the short-term) than information that is simply read.

Many anti-smoking campaigns try to “educate” people out of smoking cigarettes. They provide a great deal of information on the potential health hazards of smoking and try to convince smokers to quit. This approach can be dangerous as smokers might feel as though they are being attacked and react defensively. The truth is, many smokers already understand the consequences of tobacco use. If anti-smoking campaigns could find a way to develop personal beliefs against smoking, smokers might have an easier time not lighting up.

Citation:

Müller, B., van Baaren, R.B., Ritter, S.M. (2009) Tell me why…the influence of self-involvement on short term smoking behavior, Addictive Behaviors, 34(5)

Quitting smoking ‘on the spot’ is more likely to succeed than a quit attempt planned in advance

Christopher Russell

Readers who are smokers will likely have heard that if you approach stopping smoking like any other major life change, with careful preparation and planning, you can succeed, and that quitting depends first on putting together a plan that will work for you. These beliefs stem from the prevailing model of how people stop smoking which states that smokers moves through a succession of motivational stages involving contemplating stopping, preparing to stop, and then subsequently trying to stop (Prochasksa & Velicer, 1997). Consequently, physicians, GPs and smoking cessation therapists have been charged with using the model’s ‘four As’ – ask, advise, assist, and arrange – to guide smokers through these stages of change (Royal College of Physicians, 2000). This typically involves assisting smokers to anticipate potential difficulties in the early stages of quitting (e.g. identify the people, places, and things which stimulate craving), make plans to avoid/resolve these difficulties, set a date on which they plan to have stopped smoking completely, and plan rewards for maintaining abstinence between now and the quit date.

Based on this philosophy of “fail to prepare, prepare to fail”, the overarching goals of current cessation guidelines are to identify the smoker’s current stage, make recommendations appropriate for this stage, and guide the smoker sequentially through to the final stage of putting the quit attempt into action. However this model has been criticised on many grounds, the most notable being the lack of evidence that most smokers actually plan their quit attempts in advance and that doing so increases their chance of success. Indeed, this model conflicts with the accounts of many ex-smokers who say they just decided to stop smoking one day and have not looked back since.  In response to this gap in the literature, two relatively recent studies – one each in Canada and England – investigated the extent to which smokers plan their quit attempts and the extent to which planning increased the  success of quit attempts.

 The benefit of deciding to stop smoking immediately

Larabie (2005) found that while the majority of smokers (63%) planned their quit attempts in advance, the interesting finding was that the 67% of ex-smokers (i.e. successful quitters, defined as those who had not smoked in the past six months) had not planned their successful quit attempt in advance compared to 33% of ex-smokers who planned their successful quit attempt in advance. The three most commonly reported types of planning were (1) planning to quit on a significant date (e.g. birthday, New Year’s Day); (2) planning to obtain nicotine replacement medication in the near future); and (3) planning to quit once they had smoked all the cigarettes in their current carton.

Some examples of the unplanned quit attempts reported are given below, and more are available at the link in the references:

“I found out I was pregnant and I just quit” (LV, age 36).

 “I just felt like I had had enough and it was not going to kill me” (CB, age 36).

“I got ‘the scare’. I went out from work to have a cigarette and got a severe dizzy spell and had difficulty walking for 20 minutes. I quit on the spot. I still had cigarettes left in my pack” (LF, age 40).

Just as interesting was Larabie’s finding that 79% of successful quit attempts were made unassisted (defined as no use of Bupropion, nicotine patches, nicotine gums, tapering, or hypnosis). Larabie’s findings therefore argue against the prevailing model that successful smoking cessation depends on receiving assistance to quit (from medications, counselling etc) and planning quit attempts in advance. Rather, the most effective quit attempts were found to be those done without prior planning and without assistance! The paradox in this, noted by Larabie, is that health care providers may actually be hindering smokers’ chances of quitting by dissuading unassisted quitting (and promoting the uptake of formal treatment programmes) and by discouraging sudden, unplanned quit attempts. These assumptions deserve testing in their own right.

 A similar story in England

West and Sohal (2006) observed a similar success of unplanned quitting in their survey sample of 918 smokers and 996 ex-smokers in England. Almost half of all quit attempts (48.6%) were made without prior planning. Of the 611 quit attempts made between six months and five years previously, 65.4% of unplanned attempts lasted at least six months without smoking compared with 42.3% of planned attempts. This means that smokers who made unplanned quit attempts were 2.6 times more likely to still be not smoking six months later than those who made planned quit attempts. Likewise, smokers who made an attempt to stop smoking between six and twelve months previously were 2.5 times more likely to still be not smoking six months later than smokers who planned their quit attempts.

 Conclusion

A sudden decision to not smoke any more cigarettes was both common and more likely to be successful than were quit attempts made after a period of planning. While this does not necessarily suggest that planning and forethought and promoting treatment options are counterproductive, it does provide a strong case for health care providers going against current guidelines to encourage smokers, particularly those on the cusp of wanting to quit, to recognise and act upon opportunities to quit on the spot. In challenge to the prevailing ‘stages of change’ model, findings from these two studies should encourage smokers to consider the benefits of not thinking ahead, not waiting until Monday or the New Year, not waiting till the carton is empty, but instead, quitting now, without warning, or a running start, or a few days to prepare. West and Sohal state that even small changes in a smoker’s motivation to quit can trigger big changes in his/her behaviour and so smokers should be encouraged to capitalise on any desire to stop smoking. For those readers who are thinking about stopping smoking, planning may help, but consider the larger benefit of quitting today, right now.

Please write your comments in the box below.

 Just for fun

The questions asked of smokers and ex-smokers in West and Sohal’s study are provided below. If you have tried to stop smoking or are an ex-smoker and feel comfortable answering, how would you answer?

Q1. Which of these statements best describes how your most recent quit attempt started?

(a)    I did not plan the quit attempt in advance; I just did it.

(b)   I planned the quit attempt for later the same day

(c)    I planned the quit attempt the day beforehand

(d)   I planned the quit attempt a few days beforehand

(e)    I planned the quit attempt a few weeks beforehand

(f)    I planned the quit attempt a few months beforehand

(g)   Other

(h)   Cannot remember.

Q2. How long did your most recent quit attempt last?

References:

Larabie, L. (2005). To what extent do smokers plan quit attempts? Tobacco Control, 14, 425 – 428.

Larabie, L. (2005). To what extent do smokers plan quit attempts? Appendix A: Examples of responses. Accessible at:

http://tobaccocontrol.bmj.com/content/suppl/2005/11/23/14.6.425.DC1/146425_datasupplement_appendix.pdf

Prochaska, J. O. & Velicer, W. F. (1997). The transtheoretical model of health behaviour change. American Journal of Health Promotion, 12, 38 – 48.

Royal College of Physicians (2000). Nicotine addiction in Britain. London: RCP.

West, R. & Sohal, T. (2006). “Catastrophic” pathways to smoking cessation: findings from national survey. BMJ, 332, 458 – 460.

The genetics of quitting smoking- Bupropion and nicotine metabolism

If you’ve been reading A3 for a while, you know that we’re big supporters of scientific progress in addiction treatment. While it may be true that addicts need to want recovery in order to truly turn their lives around, the choice is hardly ever that simple and if we can tip the balance in the favor of treatment, or a better way of life, I say let’s go for it. When it comes to genetics and addiction, I’ve normally talked only about the fact that a person’s genetic code may predispose them to addiction or to other related conditions (like depression, anxiety, and so on). Aside from a single mention of pharmacogenomics, I don’t think I’ve spoke much about the way genetics can help us tailor addiction treatment to individual needs. We’re about to fix that.

Replacement therapies and quitting smoking

You’ve heard of nicotine patches and gums, right? In the research community, those are all known as Nicotine Replacement (NR) therapy and they’ve proven to be some of the most helpful tools for those who are quitting smoking. By allowing smokers to still get the nicotine their body craves (even though there are thousands of other chemicals in cigarettes that likely make them even more satisfying) without having to light up, these NR methods let cigarette addicts get their NIC fix while slowly lowering their dose and getting away from the habit of putting a cigarette in their mouth. Like methadone, buprenorphine, and other replacement therapies, the idea is to move addicts one step away from the actual addictive behavior and allowing them to begin adopting a healthier way of living. Replacement therapies are very successful, even if some people hate the idea of giving drugs to drug addicts, and nicotine replacement works well by itself for some people (though only about 20%).

But when it comes to nicotine, like with many other drugs, different people metabolize the stuff at different rates. The individual variability in the internal processing of nicotine greatly affects how many cigarettes individuals smoke and also the probability that they will become addicted to tobacco (people who metabolize nicotine more quickly smoke more and are more likely to become addicted to smoking). Fast metabolizers are also half as likely to be able to use nicotine replacement alone to quit smoking (1). However, when you put all of the addiction research together, it becomes pretty obvious that the same variability in nicotine metabolism can also help us determine the best course of treatment for tobacco addiction.

Metabolism, treatment, and the best way to quit smoking

Bupropion helps fast metabolizers increase their quitting chancesFortunately for smokers, the only research finding in this area hasn’t been that slow metabolizes have a much better chance of quitting smoking with nicotine replacement therapy. The same group of addiction researchers (led by Caryn Lerman of University of Pennsylvania), also found that buporopion, the smoking cessation medication everyone knows as Zyban (and the antidepressant called Wellbutrin), could help those fast metabolizers catch up with the slow metabolizers when it came to quitting (see the figure on the left taken from the actual study – you see that the dark bars, who are the bupropion patients, do as well as the white bars regardless of their metabolism rate, which is on the bottom). The researchers found that while slow matabolizers of nicotine did much better with simple smoking cessation therapy and fast metabolizers did very poorly (30% versus 10% quit respectively in each of the groups), adding bupropion made all groups look essentially the same (2). The moral? While those slow metabolizers don’t really get much of a benefit from using bupropion since they do pretty well with talk therapy or nicotine replacement alone, the fast metabolizers really need it to even their chances of quitting – and once they get bupropion, they do pretty well!

Genetics and addiction treatment – is this just the beginning?

Hopefully you’re now convinced that genetics can really help us determine what treatment course will best suit a specific person over another. There’s little question that this sort of approach is in its infancy, and you certainly can’t go to a doctor right now and get your metabolism rate for a drug analyzed (unless you’re part of a research study), but this sort of work shows great promise in improving the outcomes of addiction treatment. When you look back at that original paragraph, and the quite common thinking that addicts need to WANT to be better – I would argue that those fast metabolizers probably wanted to quit smoking as much as anyone else in the study, and their physical makeup just made it that much more difficult for them. I think that if you look at the science of addiction closely, you’ll find that this supposed lack-of-motivation is sometimes more of a myth than a reality. Many addicts want to get better, they want to stop behaving in ways that specifically mess up their lives but they just find it incredibly difficult. My hope is that this is where science can truly make a difference, by making it just a little bit easier…

Hopefully one day we’ll be able to specifically adjust addiction treatment programs according to individual patients’ needs, including the use of medications, specific behavioral treatments, and more.

Citations:

1) Robert A. Schnoll, Freda Patterson, E. Paul Wileyto, Rachel F. Tyndale, Neal Benowitz, & Caryn Lerman. Nicotine metabolic rate predicts successful smoking cessation with transdermal nicotine: A validation study (2009).

2) F Patterson, RA Schnoll, EP Wileyto, A Pinto, LH Epstein, PG Shields, LW Hawk, RF Tyndale, N Benowitz & C Lerman1. Toward Personalized Therapy for Smoking Cessation: A Randomized Placebo-controlled Trial of Bupropion (2008).

Depression and smoking relapse: Anhedonia doesn’t feel good.

A recent study published in the Journal Nicotine & Tobacco research suggests that a particular aspect of depression, namely anhedonia, a.k.a “inability to feel good,” plays an important part in predicting how quickly smokers will relapse after trying to quit smoking. When it comes to addiction research, you can’t get much clearer than these results.

Quitting is smoking is difficult, especially when you're depressed.

The researchers specified a number of factors in depression including: negative affect (feeling down), vegetative state (not moving much), and anhedonia, measuring that last one by making participants rate their expected pleasure to hypothetical pleasurable situations they were asked to imagine. They then split up the participants into three different treatment conditions that included slightly different procedures meant to help them quit smoking. All participants quit smoking immediately after attending the one-day assessment and instruction session. Following that day everyone returned to the lab after 24 hrs, 48 hrs, and then weekly for a total of four weeks to assess their smoking using fancy lab equipment.

When the researchers looked at the results, they saw that when separated into “high-anhedonia” and “low-anhedonia” groups, participants in the “high-anhedonia” group relapsed to smoking much more quickly, even when controlling for depression symptoms before quitting. In fact, 20 days after that initial session, more than half of the “low-anhedonia” participants were still not smoking while essentially none of the “high-anhedonia” participants had managed to quit.

As if it is isn’t hard enough to quit smoking, apparently, feeling like $&%@ just makes it harder… Hey, I never said addiction research would always bring good news!

Citation:

Cook, Spring, McChargue, and Doran (2010). Effects of anhedonia on days to relapse among smokers with a history of depression: A brief report. Nicotine & Tobacco Research.

About Addiction: Smoking, Alcohol, Painkillers, Prescriptions

This are new, interesting articles about addiction. Check out the links to the articles, and give us your feedback.

Smoking and related issues

Health Day: Smoking increases the risk of age-related macular degeneration, a disease that robs people of their sight.

Reuters: When cigarette smokers quit smoking, chronic stress levels may go down. This should give smokers reassurance that quitting will not deprive them of a valuable stress reliever.

Reuters: A nicotine mouth spray may help prevent cigarette cravings three times faster than nicotine lozenges or chewing gum. This might help smokers who are trying to quit smoking.

Cesar Fax: The percentage of national tobacco retailers selling to minors appears to have leveled off. The average national retailer violation rate decreased from 40.1% to 10.8%, and stabilized at 10.8%.

wcstv: Under a proposed deal reached by Governor David Paterson and Albany legislators, cigarette taxes would increase by $1.60 per pack. In New York City, the price of one pack of cigarettes would cost over $10 in many stores. The hope is that this huge price increase will help smokers quit smoking and reduce overall levels of smoking in New York.

About addiction to alcohol, painkillers, and prescription medication

Hazelden: Abuse of alcohol, painkillers, and prescription medication is rising dramatically among older people. Signs of alcohol abuse and drug addiction are different in older adults than in younger people.

Science Daily: Religiosity can moderate genetic effects on alcohol abuse during adolescence but not during early adulthood. The heritability of an alcohol abuse phenotype depends upon the social environment within which it is measured.

Medical News TODAY: Sleep problems can predict the onset of alcohol abuse in healthy adults and relapse in abstinent alcoholics. Puberty is related to sleep problems and later bedtimes, which are associated with alcohol abuse.

Health Day: Exercise may be an effective treatment option for alcoholism. In addition, alcoholism disrupts normal daily circadian rhythms, which can lead to disrupted sleep patterns.

About addiction and mental illness

KansasCity.com:  To study drug addiction and mental illness researchers, at the University of Missouri-Kansas City, have received a $1.8 million federal grant. One of the leading researchers states that conditions such as drug addiction and depression are major problems across the globe.

More to cigarettes than nicotine

A recent talk I gave (click here), highlighted the fact that other aspects of smoking are very important for addiction to cigarettes. For some people, this isn’t news, especially if you’ve been reading our coverage about the importance of cues for smoking addiction. But that’s not all that makes cigarettes so hard to quit.

Cigarettes, chemicals, and addiction

Smoking addictions are very difficult  to quit

Thousands of chemicals are released when cigarettes are smoked, including the nicotine we’ve been hearing so much about as well as formaldehyde, benzene, and other nasty things. Some of the chemicals that are released have psychoactive effects, and a few, like acetaldehyde (the chemical that causes hangovers), and a group of monoamine oxidase inhibitors (yes, like old school MAOI antidepressants), apparently increase the effects of nicotine itself greatly, making it far more rewarding, and therefore theoretically addictive, than it would be without them.

The recent paper by a group at Duke University, suggests that there may be aspects of the smoke in cigarettes, even without nicotine, that are themselves rewarding. In the study, researchers gave people the option of taking nicotine by IV or smoking a de-nicotinzed cigarette – Overwhelmingly, participants chose to smoke the nicotine-free cigarettes.

Limitations and conclusions

Now granted, these were regular smokers, which meant that regardless of the effect, the act of smoking was so pre-programmmed for them as a rewarding one that overcoming it just for an experiment is a far-fetched notion. Still, given the hard time I’m having using nicotine as a reward, it seems likely that the other chemicals, as well as the experience of the smoke itself, play a very important role in addiction to cigarettes. Indeed, researchers years ago were very interested in discussing the role off the insula, a brain region important for bodily sensations (possibly involved in cravings and urges).

Another important limitation of this study was the fact that the “de-nicotinized” cigarettes actually had very  small amounts of nicotine in them. This little tidbit of  information is important because even small, “priming,” doses of a drug can cause very strong effects in terms of drug-seeking and drug-wanting. Maybe in the future there’d be some way of repeating this sort of study with cigarettes that actually contain no nicotine whatsoever.

Citation:

Rose, J.E., Salley, A., Behm, F.M., Bates, J.E.,  and Westman, E.C. (2010). Reinforcing effects of nicotine and non-nicotine components of cigarette smoke. Psychopharmacology, 210, 1-12.

Cigarettes, smoking, and drinking alcohol – The connection that may help you quit smoking

Contributing co-author: Andrew Chen

It’s no secret that alcohol and cigarettes go hand in hand, but for most drinker-smokers, the reasons are probably a mystery. Does alcohol simply make people less able to control urges or is there something more direct about the connection between the two?

Alcohol reduces control over cravings

Smoking and drinking

A recent field study published in Psychology of Addictive Behaviors examined exactly this question using 74 smokers who recorded their daily experience in a journal. Researchers found that alcohol consumption was associated with more frequent urges to smoke, signaling that indeed, drinking may increase the “want” while lowering the ability to control the cravings. However, the study also found that smokers reported greater satisfaction after smoking while they were drunk. Alcohol consumption predicted higher ratings of cigarette buzz, taste, and urge reduction after smoking.

Timing and context are important

Interestingly, the effects reported were only observed within the first hour after drinking, a period when alcohol content (BAC) is rising. (2)

Last but not least, situational factors seem to account for some of the effects of alcohol on smoking. Settings like bars and restaurants, where smoking and drinking were permitted, were associated with more frequent urges to smoke and greater satisfaction after smoking. Social settings, like being around drinkers and smokers, are also associated with increased urge and satisfaction.

How to quit smoking? Reduce, or stop, drinking

So, if you’re trying to quit smoking, cutting down on drinking, at least in the initial phases of your quitting attempts, might be a good idea. It may reduce your cravings, and it may make you like the smoking a bit less while you’re quitting. If nothing else, it’ll get you out of situations where smoking occurs most often which will, by itself reduce your smoking.

Citations:

1. Henningfield, J. E., Chait, L. D., & Griffiths R. R. (1984) Effects of Ethanol on cigarette smoking by volunteers without histories of alcoholism, Psychopharmacology, 82, 1-5

2. Piasecki T.M., McCarthy D.E., Fiore M.C., & Baker T.B. (2008) Alcohol consumption, smoking urge, and the reinforcing effects of cigarettes: An ecological study. Psychology of Addictive Behaviors, 22(2):230-9.