How To

When smokers try to quit without medication or counseling, 4 percent to 6 percent will succeed. But those who get face-to-face counseling, nicotine-replacement therapy and medication can quadruple that success rate.

That's why psychologists need to take an active role in helping smokers quit, says Timothy Baker, PhD, who served as senior scientist to this year's update of the U.S. Public Health Service's clinical practice guidelines for smoking cessation. As Baker sees it, psychologists will likely encounter smokers in their work because research has found that people with diagnosed mental disorders are twice as likely to smoke than people with no mental health concerns. In addition, he said, it's more likely that tobacco will kill them than the problem for which they sought therapy. In fact, smokers have a 50 percent chance of dying from tobacco-related diseases.

Counseling combined with medication produces the highest success rates, says Baker, who is director of research for the University of Wisconsin's Center for Tobacco Research and Intervention. In addition, there is a dose-response relationship between the number and duration of counseling sessions and smoking abstinence: Clinicians should meet for a minimum of four 10-minute sessions with patients trying to quit, and more sessions and longer sessions are associated with better outcomes.

The guidelines recommend practical, problem-solving counseling that helps a smoker recognize danger situations, in terms of events, feelings or activities that increase the risk of relapse, and develop coping skills to deal with those situations.

"There's an imperative for every psychologist who has a patient who smokes to bring that up and take action," he says.

Tested techniques

Psychologists have decades of experience helping smokers quit. Here are some of their research-tested approaches:

  • Motivational interviewing. For longtime smokers, smoking is their main coping mechanism to deal with the stresses of life, even though they know it's an unhealthy, stigmatized habit that sends them out in the cold and the rain to get a smoke, says Marc Steinberg, PhD, director of the Mercer County Tobacco QuitCenter in New Jersey.

In motivational interviewing, counselors acknowledge the benefits or pros of smoking for the person but also ask the smoker to consider reasons they might want to quit, or the cons of smoking.

"We try to help them resolve that ambivalence, to see that it's very normal to want to quit smoking and not want to quit smoking," Steinberg says.

During the interviews, counselors listen for and encourage "change talk" from the smokers—reasons why they want to quit, why they're confident they can and why they're committed to change, he says.

The approach was developed for use with problem drinkers in the early 1980s by William R. Miller, PhD. The center has been using motivational interviewing with smokers for about five years. A study published in 2004 in the Journal of Counseling and Clinical Psychology (Vol. 72, No. 3) points to the technique's success: It found that both nicotine-replacement therapy and motivational advice increase future quit attempts among smokers who are unmotivated to quit.

Once smokers become highly motivated to quit, the next step is moving to a skills-based model and teaching them specific skills to help them stay abstinent, Steinberg says.

  • Distress-tolerance treatment. This approach is designed to help a subpopulation of hard-core smokers who want to quit. They seem unable to tolerate the discomfort of even an hour without a smoke, says cessation researcher Richard A. Brown, PhD, a professor at Brown University and director of addictions research for Butler Hospital in Providence, R.I.

Brown is also interested in helping smokers who are dealing with depression. More so than others, these smokers seem to turn to a cigarette whenever something bad or disappointing happens or when they feel irritable, sad or angry, Brown says.

To help these difficult-to-treat smokers, Brown and his colleagues have developed a distress-tolerance treatment, which draws components from acceptance and commitment therapy, holding to the idea that some people try to avoid negative emotions. One method, akin to exposure therapy with anxiety disorders, is to have smokers refrain from smoking for several hours and work through a range of exercises. Instead of avoidance, the treatment teaches smokers that despite strong negative feelings, they can adapt and acclimate to the negative emotions that trigger relapse and still accomplish their goals.

According to the results of a pilot study of 16 smokers who had never been able to quit for longer than 72 hours in the past 10 years, seven were able to remain abstinent for more than a month after going through six weeks of distress-tolerance treatment.

  • Changing habits. As part of a formal program of tobacco cessation called QuitSmart, psychologist Robert Shipley, PhD, president of QuitSmart Stop Smoking Resources Inc. and director of the Stop Smoking Clinic of the Duke University Addictions Program, says smokers need to change the habits and routines they formerly associated with smoking, such as lighting up a cigarette after a meal, while having a cup of coffee or on a work break.

"We say that the habit is strong, but it's dumb," says Shipley. "If you change some part of it you won't get as strong an urge because the habit is so tied to specific cues that have been repeatedly paired with smoking," he says.

According to a study of QuitSmart's results compared with four other interventions, 66 percent of smokers who participated in four QuitSmart sessions and received nicotine-replacement therapy were abstinent six months later. The other interventions, which also included nicotine replacement therapy, achieved between 16 percent and 30 percent abstinence.

  • Coping skills and strategies. Successful tobacco cessation requires people to stop seeing themselves as smokers or users of tobacco. Shipley encourages them to "fake it till you make it" and view themselves as calm, comfortable nonsmokers through such relaxation techniques as deep breathing, muscle relaxation and physical exercise.

Each person who enrolls in QuitSmart gets a hypnosis compact disc with two tracks to guide them through self-hypnosis sessions at home. A client is encouraged to listen to the first "Quitting" track for 15 minutes twice a day for a week, followed by the "Remaining a nonsmoker" track starting the second week.

During withdrawal, when a client is feeling angry or irritable, Shipley raises clients' awareness of the positive physical changes that happen within days of no longer smoking, such as pinker skin from better blood flow and warmer hands and feet.

Also as part of Shipley's QuitSmart program, smokers receive a realistic plastic cigarette on their quit date. Based on the classic principles of Pavlovian conditioning, smokers use the fake cigarette in a variety of daily situations when they feel tempted to smoke. Over several weeks as the fake cigarette fails to deliver nicotine, the association between real cigarettes and the reward of nicotine is gradually extinguished.

The fake cigarette also causes the user to take deep relaxing breaths and gives the smoker something to do with his or her hands and mouths, Shipley says.

  • Nicotine fading. This technique has smokers gradually switch from their usual brand of cigarette to lower nicotine brands over a two-week period. Smokers are cautioned not to compensate by smoking more cigarettes or inhaling more deeply.

The typical smoker might be using a brand rated at more than 1 milligram of nicotine per cigarette. The smoker would switch to a brand rated at 0.4 milligrams for one week, then for one week to a brand rated at less than 0.2 milligrams, then stop smoking completely.

Besides helping smokers "wean" themselves off nicotine, the fading process decreases the reward associated with smoking, Shipley says.

  • Social support and pledging. Charles Dodgen, PhD, a New Jersey-based practitioner and author of "Nicotine Dependence" (APA Books, 2005) gets his clients to identify a person who will support their quit attempt and talk to him or her when they're close to relapse. Smokers with social support do better in cessation attempts than those without such support, Dodgen says. The role is formalized with a signed contract, spelling out the smoker's responsibilities and ways the sponsor can help, including encouraging healthy activities and accepting the smoker's bad moods or negativity. Smokers are also asked to sign a pledge with a set quit date, mutually agreed upon after talking with the therapist.

"By making a formal pledge, it helps them to take a little bit of ownership and personal responsibility for the process," Dodgen says.

  • Stimulus control. Before a client reaches his or her quit date, Dodgen works with them to first identify, then stay away or limit contact with people, places and things they associate with smoking so that when they do stop, they're not constantly reminded of smoking.

Several of Dodgen's approaches are included in actions recommended within the clinical intervention strategy laid out in the Public Health Service's guidelines, the 5 As (Ask, Advise, Assess, Assist and Arrange).

Further information: