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.

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.

Does current smoking among health care providers limit their ability to dissuade smoking to the general public?

By Christopher Russell

In 2003, the US Department of Health and Human Services (USDHHS) set a goal of reducing cigarette smoking among US adults (18 years +) to 12% by 2010, which if achieved would halve the adult smoking prevalence rate reported in 1998 (24%). Achieving this current smoking reduction may depend on the extent to which health care providers (doctors, nurses, and such), who are charged with promoting smoking cessation and dissuading the uptake of smoking among to the general public, are themselves current smokers. For example, health care providers’ anti-smoking and pro-quit messages will likely be more persuasive and credible to the smoking public when the messengers practice what they preach about smoking. Such messages may also better motivate quit efforts if the health care providers have had personal success in quitting smoking using the methods and information they are now endorsing. Conversely, smokers may intuit that when health care providers advise quitting but continue to smoke themselves despite enjoying ready access to all the resources, information, and tools which should facilitate quitting, then smokers, without this luxury of access to education and resources, will be even less likely to successfully stop smoking.

Therefore, significant strides in increasing the number of quit smokers and never smokers in the general population may somewhat depend on reducing current smoking among the health care providers who act as both educators and trusted role models to the general public. It is therefore important to know how the prevalence of smoking among health care providers compares to the prevalence of smoking in the general population, which health care providers are charged to reduce.

Current smoking among health care providers

Using US population survey data, a recent study published in Nicotine and Tobacco Research reports estimated changes in the prevalence of current smokers, former smokers, and never smokers among eight groups of health care provider  – physician, physicians assistant, registered nurse (RN), licensed practical nurse (LPN), pharmacist, respiratory therapist, dentist, and dental hygienist – between 2003 and 2006/07. While the majority of these health care providers have never smoked a single cigarette, the authors report that, in 2006/07, approximately one in every five licensed practical nurse (20.55%) and respiratory therapist (19.28%) was a current smoker. Current smoking rates among LPNs and respiratory therapists were marginally higher than the rate of current smoking in the general population (18.01%) and near double the Healthy People 2010 goal of 12% current smoking in the general population. Four groups of health care provider – physicians (2.31%), dentists (3.01%), pharmacists (3.25%), and registered nurses (RNs) (10.73%) were all on course to be below the 12% prevalence goal. Furthermore, seven of these eight health care groups in 2006/07 showed higher quit rates than was found in the general population (52%) – only LPNs had a lower quit rate (46%). However, the concern from a public health perspective, is that while current smoking rates among these health care groups and in the general population have dropped considerably when compared to data reported in a similar cohort study in 1990/91, these decreases in current smoking appear to have leveled off in recent years; current smoking did not significantly decrease in any health care profession or in the general population between 2003 and 2006/07.

An important methodological note about this study is that results reflect weighted population estimates (WPE), not actual data. WPEs allow researchers to make inferences about an entire population group given only some data for that group simply by scaling up the actual data, (i.e. data reported by around 4000 health care providers in each collection year were used to estimate smoking statuses for over 2 million actual individuals). Of course, this technique likely overgeneralizes behavior in the sampling group, but is nonetheless a standard, valuable tool of health epidemiologists when they want to make inferences about how entire populations are behaving. Indeed, many of our health policies have derived from WPEs.

Current smoking among licensed practical nurses

Among the most important findings of this study is that one in five licensed practical nurses in the US is currently smoking. Of the estimated 754,000 LPNs in the US, this equates to roughly 155,000 current smokers in this profession, illustrating that health campaigns designed to depict smoking as socially unacceptable, readily available access to education and empirical research on the health consequences of smoking, working in smoke-free health care campuses, and being charged with task of persuading clients to stop smoking, all appear insufficient to reduce current smoking among LPNs and respiratory therapists to below the rate of current smoking in the general population.

In contrast, 10.73% of registered nurses are current smokers. The discrepancy between LPNs and RNs begs two questions: why are LPNs nearly twice as likely as RNs to be current smokers, and should we expect RNs will be better able than LPNs to persuade current smokers to quit and dissuade smoking to would-be smokers? Certainly, researchers should now ask whether a health care provider’s smoking status is related to his ability to produce cessation in health care recipients. If we assume that health care workers have a central role to play in producing mass behaviour change of whatever kind, then it is plausible to reason that reducing smoking prevalence at the national level will significantly depend on first reducing smoking prevalence among health care providers, our first responders to public health concerns. Testing this hypothesis seems the logical extension to capitalise on these smoking prevalence data.

Why are licensed practical nurses twice as likely as registered nurses to be currently smoking?

If one’s smoking status is important for persuading change in others, we need to know why smoking is more prevalent among LPNs than RNs, why LPNs have a lower quit ratio than the general population, and so, which factors should be addressed to reduce current smoking among LPNs to below the 12% level. The authors of this study suggested that LPNs’ fewer years in education and lower annual income may be associated with their current smoking status since they mirror socioeconomic factors known to associate with higher smoking rates. Comparably large proportions of LPNs and RNs are female, thus ruling out an important effect of gender. In my opinion, given that nicotine produces positively reinforcing psychoactive effects and that smokers commonly report smoking to alleviate affective distress, another consideration may be that LPNs and RNs differ in their exposure to stressful work events and environments, and/or differ in their emotional reactivity and sensitivity to these events, and/or differ in their bias to perceive work events as stressful. Furthermore, as smoking staus is known to be associated with socioeconomic status and socioeconomic status is known to be associated with many health and wellbeing factors including stress, then stress may be important both as a direct influence on smoking behavior and indirectly as a mediator of the effects of socioeconomic variables on smoking behavior. A good start to exploring these hypotheses would be to simply ask LPNs and RNs of their main reasons for smoking in short open-ended interviews; if reliable differences in smoking attributions emerge then we may begin the harder task of counseling LPNs to think of smoking in ways which alter their reasons to smoke, the reasons which may currently be maintaining smoking in one in five LPNs.

Questions for the reader; please give your comments below

1)      Why do you think current smoking is more prevalent among licensed practical nurses than in the general population?

2)      Does a health care provider’s status as a current smoker make him/her more or less able to persuade smoking cessation in others?

3)      Will reducing current smoking nationally depend on reducing current smoking among health care providers?

References:

U.S. Department of Health and Human Services. (2003). Healthy People 2010, Retrieved from http://www.healthypeople.gov/

This report is free to download at: http://www.healthypeople.gov/document/pdf/uih/2010uih.pdf

Sarna, L., Bialous, S. A., Sinha, K., Yang, Q., & Wewers, M. E. (in press). Are health care providers still smoking? Data from the 2003 and 2006/2007 Tobacco Use Supplement-Current Population Surveys. Nicotine and Tobacco Research.

Quitting smoking: Quitlines success

In the world of extremely difficult smoking-cessation (quitting smoking), telephone-based programs are apparently having some real success.

Quitting smoking with quitlines

According to a recent summary-analysis (we call these meta-analyses) of research done on Smoking Cessation Quitlines (CSQs), smokers who call and participate are 1.5 times more likely to quit! These are roughly the same numbers we see for people who use nicotine replacement therapies (NRTs, like the nicotine patch, gum, or lozenge), which are the most successful therapies we’ve got. Not bad when you consider that most quitlines are free to users.

What do quitlines do?

Once a user interested in quitting contacts a CSQ, they are taken through an assessment procedure. The California one is apparently pretty long, lasting 30-40 minutes. Don’t worry, the first call is the longest. Past this point, the lines’ activities vary greatly depending on the specific provider. Some offer phone-based counseling only, others also mail materials, and some offer recorded messages, on-demand counseling, counselor callback, and even access to medication (like patches, gum, or bupropion). Since state-based ones are free, it’s a good idea to make the call and see what your state offers. If you’re an addiction professional, or a psychologist with clients that want to quit smoking but can’t seem to shake it, this might be a great suggestion for them.

Can quitlines be used for other addictions?

Phone-based interventions have already been used for some addiction problems (mostly problem drinking), but usually as a supplement to face-to-face treatment. Still, given the relatively low cost associated, it seems that establishing such a tool for problem drinkers that doesn’t include a face-to-face interaction could be a viable option. Since it was state-based public health officials that made CSQs happen through lobbying, it seems that any addiction, or mental health, problem that is prevalent enough to warrant such attention (and such expenditures) may benefit from a little quitline love.

Citation:

Lichtenstein, E., Zhu, S.H., Tedeschi, G.J. (2010). Smoking cessation Quitlines: An underrecognized intervention success story. American Psychologist, 65, 252-261.

Triggers and relapse, a craving connection for addicts

I’ve already written about one reason why cravings make quitting difficult (find it here). However, cravings and triggers are not just abstract concepts; they are well known, important players in addiction research and I think they deserve some more attention.

What are triggers?

A trigger can be thought of as anything that brings back thoughts, feelings, and memories that have to do with addiction (like a computer reminding a sex addict of porn). In addiction research, these are often simply called cues. The word comes from learning research in which a reward (or punishment) is paired with something (the cue).

For instance, in Pavlov‘s classic experiment, a dog heard a bell ring right before it would get served its daily portion of meat. The dog quickly learned to associate the bell with food, and would begin salivating as soon as the bell would ring, even before the food was presented. In this case, the bell was the cue, and food the reward it was paired with.

The story in drug addiction is similar. I’m sure many of you can relate to the overwhelming memories and emotions that seem to come out of nowhere when you hear music you used to get high to or pass a street where you used to buy drugs (or sex). Each of those examples is a trigger that is simply bringing about a similar reaction to Pavlov’s dog’s salivation. Seeing these things, or hearing them, creates an immediate response to the reward that it was paired with, the drug!

Triggers, cravings, drugs, and relapse

As if matters needed to be made worse, triggers not only bring about responses that make you think about the drug. In fact, over and over in learning and addiction research, it’s been shown that triggers actually bring back drug seeking, and drug wanting, behavior. As soon as a cue (or trigger) is presented, both animals and humans who have been exposed to drugs for an extended period of time, will go right back to the activity that used to bring them drugs even after months of being without it. In fact, their levels of drug seeking will bounce back as if no time has passed. Sound familiar?!

Given these findings, is it any wonder that cravings bring about relapse in so many addicts who are trying to quit? If simply thinking about, or hearing, something that was always tied to drugs can bring about such a strong response, what is an addict to do?

Is there a solution for addicts??

For now, the simplest way to break the trigger-response connection is simply repeated exposure without the reward. As bizarre as this may seem, staying away from the triggers can make their ability to bring back the old drug-behavior stronger. Obviously, this isn’t something that should be undertaken lightly. I’m currently working on putting together a drug treatment system that specifically addresses these issues so that with help, users can eventually release the hold that triggers have over them.

In the meantime, be honest with those around you, and if you’re seeing a therapist, or a good case manager, tell them about your triggers so that you can hopefully start talking about them, and re-triggering them in a safe environment. As always, feel free to email me with any questions you might have.

Always stay mindful – My different experience with recovery, addiction, and crystal meth

One of the main features of addiction is, unfortunately, how insidious it is.
Given everything I’ve been learning in the past 12 years about drugs, their abuse, and the people involved, I feel right in saying that most people don’t realize how far gone they are until it’s too late.

I consider myself fortunate in finding my way out of my crystal meth addiction, and I’ve met many others who’ve found their way as well. Still, I realize constantly that you can’t be too vigilant or too aware in watching out for inroads back to disaster.

My Experiment

methAs I’d said before, I began drinking again after 3 years of staying completely sober. My decision to leave typical recovery was made after talking with my parents and loved ones and making sure that they understood what this meant. I made sure that if I began reverting back to my old way of being lazy, aloof, and disrespectful, they would step in and send me right back to rehab.

This was my way of running the famous AA experiment and for me, it’s been working for the past 5 years or so.

But, I am always aware of how intoxicated I am and it is rare nowadays that I let myself get to the point of the loss of control. I have this constant voice in my head now that monitors how drunk I feel. I DO leave unfinished glasses of wine at dinners at times, and I do my best to make wise choices before going out so that I don’t make dumb ones later (like driving under the influence).

How I stay grounded

Still, most of my awareness about my addiction and what it means comes from my constant work in the area. Working with people who are in the throws of their disease keeps me in touch with how far I’ve gone and how much I don’t want to go back. I now know much more about the risks and about what I’d be doing to myself were I to take them. I don’t want to kill additional neurons, and I sure as hell don’t want to go through 2 more years of hell trying to put my life in order. I’ve never tried speed again since the day I quit in 2002 because I can’t say that I’m sure of what would happen next, and I don’t want to find out in case it’s bad…

This is why I believe that education is one of our best weapons in the battle against addiction.

My most valuable help

Lastly, I feel like one of the most important ingredients in all of this is having people you can trust and confide in. I don’t have many of those, but there are a few, and my family is always there, and I share everything with them.

For me, it was the moment I chose to be forthcoming with my family and hide nothing from them that has healed years of tension, mistrust and fighting, and I never want to go back .

This however means that they too have to be open. We now laugh when I say things like “I wish I could do some speed now to get me through all this work I have,” but I assure you, no one was laughing 5 years ago…

A word of caution

DefeatedMy sponsor in AA “went out” (meaning he started using again) a few months ago after being prescribed pain medication for surgery. Many in AA would point to the fact that he should have never been prescribed those pills in the first place. Everything I’ve learned about the brain indicates that automatic relapse is only likely when using one’s “drug of choice“. I say it was the dissolution of his marriage and his trust that having been sober for 12 years he could do no wrong that got him in trouble.

The moral:

Be open, accepting, and loving. Let those around you say things that make you uncomfortable without too much judgment so that they feel safe in coming back to you, and if they ask for help, know how to give it to them. No matter how happy people are to finally quit drugs (or another addiction), the feeling of defeat when they realize they now have to learn to live without their crutch can be enormous. This is where the help is most important.

Question of the day:
Do you have a story about the support you found necessary for your own recovery or the recovery of someone close to you?