Behavioral Treatment of Cigarette Smoking

Biobehavioral Model of Smoking

The most prevalent smoking cessation programs have employed behavioral principles in concert with other strategies. “Typical” behavioral treatment programs focus on antecedents and consequences of smoking and include cognitive techniques that promote coping during and after treatment. The behavioral perspective is that smoking is a learned behavior, originally initiated by psychosocial variables (e.g., adult modeling, curiosity, peer pressure, availability, rebelliousness) and maintained by physiological dependence on nicotine in combination with conditioned environmental stimuli that elicit the urge to smoke once the behavior has been firmly established. In this sense, smoking is a highly overlearned behavior. An average pack-a-day smoker puffs an estimated 160 times each day, providing ample opportunity for internal cues (e.g., anxiety, hunger) and environmental cues (e.g., drinking coffee, talking on the phone) to become associated with the urge to smoke. The act of smoking can also be heavily reinforced operantly by both internal (e.g., pleasure, craving reduction) and external (e.g., social approval from other smokers, handling the cigarette) consequences.

The aversiveness of withdrawal from nicotine must be considered in any model of smoking behavior. Self-monitoring has revealed that coughing, craving for tobacco, feelings of aggression, increased appetite, irritability, nervousness, and restlessness increase in severity during the first week after quitting, followed by a decrease in severity thereafter. Constipation and craving for sweets are at higher levels than baseline for 6 weeks after quitting. Patients who maintain abstinence for 6 weeks experience fewer symptoms during the initial 2 weeks after quitting than those who don't. In addition, at 6 weeks, abstinent patients typically experience symptoms at baseline or lower levels of severity. Clearly, many individuals experience the act of quitting smoking as aversive. The role of expectations in the experience of withdrawal symptoms has yet to be adequately evaluated.

A comprehensive biobehavioral theory of smoking must include biological factors as well. Smokers smoke to cause temporary improvements in performance and affect. There is a periodic pattern of arousal and alertness during smoking, followed by calming and tension reduction after smoking. Smoking stimulates the production of betaendorphins and vasopressin. These neurotransmitters are known to reduce pain, increase tolerance to stress, improve memory, increase concentration, and speed up information processing. Therefore, smoking is maintained by both powerful negative (e.g., reduction of craving) and positive inducements. There may even be an inherited predisposition with regard to susceptibility to these inducements.

Description of the Strategy

Cognitive-behavioral methods often employ strategies designed to counteract these negative and positive inducements to smoke. These interventions include (a) aversive strategies such as smoke holding, rapid smoking, and noxious imagery, (b) nicotine-fading and controlled-smoking techniques, (c) self-control and self-monitoring strategies that help smokers identify and modify situations, cognitions, feelings, and other cues that promote urges to smoke, (d) partner support, (e) hypnosis, (f) acceptance-based strategies, and (g) relapse prevention strategies.

Research Basis

Reports of initial cessation from behavioral programs have ranged from 50% to 100%, with relapse rates of 70% to 80% among studies that provided 3-month follow-up data. This dramatic decline from initial cessation to immediate relapse among the majority of smokers has caused a shift in emphasis toward relapse prevention among smoking researchers. Behavioral approaches have generally been found to be superior to control conditions. Successful treatment approaches, including behavioral interventions, are more successful with light smokers and obtain abstinence rates that range between 25% and 33%. At 6- and 12-month follow-ups, the “average” participant in the “average” smoking control program has a 20% chance of being abstinent. Involvement in one of the more successful programs may increase these odds to between 30% and 40%. It should be noted that most smokers quit without the help of an organized program, perhaps leaving the programs to deal with the smokers who have the most difficulty quitting.

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