Bonnie Spring, PhD, began smoking as a way to concentrate while writing papers in college. The nicotine and the ritual of lighting up later helped her think through her dissertation on schizophrenia's tangled underpinnings and write grant proposals for her research, she says. But Spring knew that along with this increased concentration came a greatly increased risk of lung cancer and heart disease, so she attempted to quit while completing her clinical internship.
"I got through the entire internship year not smoking because I was just writing [patient] chart notes," says Spring, now a health psychology professor at the University of Illinois at Chicago. "Then when I went back to writing schizophrenia research grants, I went right back to smoking."
The experience sparked Spring's interest in addictions and led her to switch from abnormal to health psychology after becoming a full professor. Spring observed that her own smoking habit had a specific purpose: She was self-medicating to concentrate. This led her to theorize that smokers use cigarettes to regulate their mood, concentration and weight, to name a few uses. Those attempting to quit smoking might have an easier time if they could replace cigarettes with something else to fill those needs, she thought--such as controlling weight with exercise and an improved diet.
After jumping fields to health psychology, Spring developed an empirically supported smoking-cessation technique that she and other psychologists are using to help people replace smoking with healthy behaviors. Moreover, they can apply the 16-week program to multiple health behaviors simultaneously, such as smoking and overeating, suggests new research by Spring and her colleagues.
"Smoking, poor diet, not exercising enough--these are the behaviors that are responsible for the most American deaths," says Spring. "Can we change more than one of these behaviors at a time?"
A two-front war
Most clinical practice guidelines and some past research suggest that when people take on more than one problem behavior at a time they often fail, says Spring. But a study by Spring, published in the October Journal of Clinical and Consulting Psychology (Vol. 72, No. 5), finds that tackling smoking and diet simultaneously does not harm clients' chances for smoking-cessation success. Moreover, the former smokers in the study learned to use physical activity rather than cigarettes to speed their metabolism--a reason many cite for smoking, says Spring.
Spring and her colleagues recruited 315 female smokers--women are the most likely to be concerned about weight gain while quitting--and assigned them at random to three different 16-week treatment programs. With an average age of 42, these women each smoked about 20 cigarettes a day at the beginning of the intervention.
One group participated in weekly psychologist-led group counseling for cigarette addiction. They discovered their smoking patterns by recording the time of day of each smoked cigarette and the events that immediately preceded the craving.
Then the participants worked with their group leader to avoid situations that led them to smoking--such as drinking in a bar--and tried alternative activities, like taking in a movie. When smoking cues couldn't be avoided, the clients tried to do things incompatible with smoking. Those who smoked after meals, for example, immediately washed dishes after eating. By the time the dishes are done, the urge to smoke has often passed, Spring notes.
"This is traditional cognitive-behavioral problem solving--partnering with smokers on a detective mission to find the hooks that bind them to smoking, and devising experiments that let them get unhooked," says Spring.
Participants in the other two conditions went through this detective mission as well, but their group leaders also taught basics of health and nutrition. They explained the importance of low-fat foods and taught the participants to avoid high-fat, high-calorie treats. Many people gain weight after they quit smoking--in part because smoking increases a person's metabolism about 100 calories a day, but primarily because they increase their consumption by about 300 calories a day, Spring says. Eating high-calorie treats, such as candy and cookies, increases brain serotonin levels, which take a dive as people quit smoking, she notes.
However, healthier foods such as pasta and whole-grain breads also increase serotonin in the brain, Spring says. So the researchers aided the dieting groups in their healthy-eating goals by providing these participants with low-fat meals for the entire 16 weeks of treatment. Each meal plan matched the level of calories the participants consumed before smoking, minus 150 calories to offset quitting-related metabolic changes. And, perhaps most importantly, says Spring, the meals included plenty of mood-boosting carbohydrate-rich foods, like pasta.
Moreover, group leaders helped the participants incorporate moderate exercise into their daily routines to maintain their weight after the end of the program.
The two smoking cessation and weight control groups differed only in the timing of the weight control aspect of the program. One group started the quit-smoking and dieting programs at week one, while the second group also began to quit smoking at week one, but waited until week nine to start dieting. Both of these groups quit smoking at about the same 20 to 40 percent rate as the group that concentrated on smoking cessation only.
The smokers on the slightly staggered schedule controlled their weight more effectively than those in other groups--gaining only 4.88 pounds on average at the nine-month follow up, as compared with the 7 pounds gained by the others.
In addition to finding that taking on both smoking and weight gain can work, this study suggests that other unhealthy behaviors, such as overeating and overspending, might also be taken on simultaneously, says Spring.
Spring's findings have spurred other researchers to tackle both weight gain and smoking within the same program, using slightly staggered schedules. One such researcher, Robert Klesges, PhD, a psychologist at the Mayo Clinic, recently began an experiment where he will try to replicate Spring's success with hypertensive male and female smokers.
"Bonnie has an extraordinary breadth in her experience--she is an expert on everything from the physiology of smoking to smoking cessation to weight gain following smoking cessation," he says.
Klesges adds that Spring's ability to draw from both behavioral psychology and medical findings have aided her in her quest to help people quit smoking.
However, notes Spring, kicking her own addiction took drastic measures. She left the field of schizophrenia research when she found she could not write about the disorder without arousing overpowering nicotine cravings.
"I shifted fields--went from being a psychopathologist to a health psychologist--because I could not break that association," says Spring. "I had to put my health concerns right to the front and center of my world to finally live right."