January 8, 2014

Psychology's Role in Smoking Decline Continues 50 Years After Surgeon General's Groundbreaking Report

Five questions for psychologist David B. Abrams, PhD

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Fifty years ago, the U.S. Surgeon General’s Report on Smoking and Health prompted one of the largest public health behavior change success stories of the 20th century. Before and since this groundbreaking report’s release, psychology has been at the forefront of smoking cessation efforts.

david-abramsDavid B. Abrams, PhD, is a psychologist and executive director of the Schroeder Institute for Tobacco Research and Policy Studies at the American Legacy Foundation in Washington, D.C. He is also a professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health and adjunct professor at Georgetown University Medical Center/Lombardi Comprehensive Cancer Center. He has been studying the science of addiction for more than 30 years and has published more than 250 scholarly articles. Abrams is author of “The Tobacco Dependence Treatment Handbook: A Guide to Best Practices.” His recent work focuses on the role research can play in informing policies for the U.S. Food and Drug Administration regulation of tobacco products.


APA recently asked Abrams the following questions.


APA: It’s been half a century since the U.S. Surgeon General’s Report on Smoking Health was released, concluding that cigarette smoking is a cause of lung and laryngeal cancer in men. How did psychology respond to the report’s findings? 

Abrams: Psychology has helped spur the dramatic reduction in the prevalence of tobacco use since its peak in the 1960s. In fact, cancer death rates are declining for the first time in a century, driven largely by the dramatic reduction in smoking rates, from 54 percent in 1965 to less than 20 percent today. Within 40 years, more than 45 million Americans have quit smoking. This is arguably one of the most successful public health behavior change interventions of all time. Psychology has played and is still playing a central role in this success story. 

Behavioral research informed the earliest behavior therapy smoking cessation interventions. Over the years, psychology also developed ways to measure what promotes behavior change and the effectiveness of behavior therapy. This led to improved clinical treatments and interventions with broad reach and efficient impact. The core of these interventions is now in a range of  programs that include self-help; online and telephone quit lines and text messages; brief treatments in primary care; intensive inpatient programs for severely addicted smokers; and treatments of smokers with other medical, behavioral health and substance abuse problems. Other successful programs include youth smoking prevention campaigns and efforts to bring anti-smoking messages and programs to low-income and underserved populations. But smoking is still the leading preventable cause of death and disease in the U.S. We are far from done. 

APA: What effect does nicotine have on emotions and the brain and how did behavioral scientists contribute to the neuroscientific understanding of the nature of addiction? 

Abrams: Animal research by behavioral scientists and human laboratory and clinical work, as well as developmental psychology, laid the foundation for discovering just how nicotine operates in the brain in terms of regulating behavior and self-control. Research on nicotine’s action on the reward pathways of the brain helps form the basis for understanding how the brain manages emotions and then informs addiction treatment. An exciting area has been the work on interaction of genes and early environment, a partnership among biomedical, genetic and behavioral sciences. Nicotine has unique properties that help regulate stress and other emotions and improve memory, concentration and attention. This may be why it is so popular and sometimes used as a “self-medication” for anxiety, depression, major mental illness and substance abuse. Developmental psychology has also shown that an unborn baby’s exposure to nicotine leads to a greater chance that the baby will have behavioral problems growing up and will lean toward nicotine dependence as a teen and adult. Peer, family and social network influences on smoking and other risky behaviors in adolescents are other areas where psychology has made valuable contributions. 

APA: There have been numerous treatments available to people who are trying to quit smoking, including nicotine replacement therapies and drugs. How has psychological research contributed to developing these treatments? 

Abrams: Psychological sciences have played a central role in explaining how drugs work and evaluating these treatments on cravings and preventing relapse, for example. This research has informed drug discovery, development and delivery, and neuroscience tools and methods in general. This work has led not only to the development of early nicotine replacement therapies that double the chances of quitting, especially when combined with the latest cognitive behavioral treatments, but also has helped in the development of drugs designed for people’s specific genetic makeup. For example, genetic studies with mice identified specific nicotinic receptors in the neural reward pathways of the brain. Newer drugs now target these receptors, further improving treatment outcomes for smoking cessation. These basic discoveries have been done with biomedical and behavioral science in a transdisciplinary, or team-science, approach.

APA: Psychological research has had a large impact on health policies associated with smoking cessation and prevention. What are some of the most important and effective policy interventions implemented over the past 50 years? 

Abrams: With prevention programs each new piece adds something, but the whole is always greater than any one part. Behavioral economics, health services and public policy research have played a central role. Increasing tobacco taxes has a very strong effect on both youth prevention and adult cessation. Mass media campaigns also work. The Legacy TRuTH campaign is credited with 22 percent of the reduction in youth becoming smokers in the early 2000s. A recent adult campaign — the CDC TIPS campaign — resulted in an estimated 1.6 million smokers making a quit attempt and more than 200,000 Americans continuing to not smoke at the end of the three-month campaign. Behavioral Internet smoking cessation programs are another recent contribution, like the BecomeAnEx website. Internet programs provide very cost-efficient and broadly accessible treatment with Web-based social support available ’round the clock. 

Smoke-free indoor air laws are also effective because they increase the cost associated with smoking. President Obama's Affordable Care Act has provisions that include coverage for smoking cessation screening and treatments for smokers. Policies within the health care delivery system can also have a large impact if fully implemented. For example, including cessation treatment as a covered benefıt signifıcantly increases the likelihood that smokers will receive treatments and succeed in quitting. These are all based on the fundamental principles of behavior change. Early detection and screening for lung cancer in smokers with more than 30 years of exposure is another new opportunity to implement behavioral science ideas at the “teachable moment” when a smoker is undergoing screening as is now recommended by the U.S. Preventative Services Task Force

APA: How can psychologists help further reduce smoking rates? And how can policymakers and researchers apply what has been learned to combat rising obesity rates, for example? 

Abrams: The psychological principles for behavior change are well established. For example, rewarding people for achieving specific quit goals, also known as contingent reward, is one of the most powerful and underutilized tools for behavior change. The lessons learned from tobacco control can be applied, with some important differences, to other health behaviors and lifestyle-related disease management. We see that behavioral principles can work very well to change an entire population in less than 50 years. What is needed for obesity is a similar comprehensive and multi-pronged approach. We also need the political will and courage among all stakeholders, including the industries that make and market foods and sugary beverages, to align policies and incentives to make healthy behaviors easier. The healthy behavior should be the easiest and least expensive behavior. Healthy lifestyles should be rewarded, with incentives at every level of our society from individuals, to families, neighborhoods, communities, the health care system, states and policies.

Special challenges for both obesity and smoking rates are health disparities such as the growing chasm in income and those with comorbid mental illness or substance abuse. This is especially problematic for lower income people with less access to healthy alternatives and little access to good health care. People and systems generally respond to aligned incentives. Success in tobacco control, although not yet complete, shows us that behavioral science does have some useful models and answers. Psychology can work with others in the biomedical and the public health arena and continue to find ways to help improve our nation’s health.

Abrams can be reached by email or by phone at (202) 454-5936. 

The American Psychological Association, in Washington, D.C., is the largest scientific and professional organization representing psychology in the United States. APA's membership includes more than 134,000 researchers, educators, clinicians, consultants and students. Through its divisions in 54 subfields of psychology and affiliations with 60 state, territorial and Canadian provincial associations, APA works to advance the creation, communication and application of psychological knowledge to benefit society and improve people's lives.