Behavioral tobacco cessation treatments: yesterday's news or tomorrow's headlines?

This article reviews behavioral treatments (broadly defined) for tobacco use, discusses cessation treatments for cancer patients, and predicts the future direction of behavioral interventions. During the past decade, progress in behavioral treatments for tobacco use has not kept pace with progress made in the development of pharmacotherapies. Nevertheless, the efficacy and cost-effectiveness of behavioral treatments compare favorably with the pharmacotherapies. Intensive behavioral interventions with empirical support are reviewed, and the difficulty of attracting smokers to intensive smoking clinics is discussed. Because there has been little research on tobacco cessation interventions designed specifically for cancer patients, clinicians should follow the Five A's suggested in the recent Clinical Practice Guidelines: Ask, Advise, Assess, Assist, and Arrange. The future of behavioral treatments will likely emphasize both minimal interventions (via telephone, Internet, and written materials) designed for broad impact and intensive interventions targeted to particular subgroups of smokers with the need and motivation for them (eg, the heavily nicotine-dependent, pregnant women, depression-prone smokers, and medical patients). A blurring of the distinctions between behavioral interventions, pharmacotherapies, and community-oriented approaches is also likely as multidimensional cessation strategies are developed.

Programmed therapeutic messages as a smoking treatment adjunct: reducing the impact of negative affect.

Maintaining treatment gains remains a challenge to smoking cessation programs. Smokers prone to negative affect are most likely to relapse. In an effort to improve maintenance, a standard cognitive-behavioral treatment was supplemented with the provision of computer-controlled audiotape players containing personalized therapeutic messages. Either the standard treatment alone, or the standard treatment plus 2 months use of the tape player were provided to 41 smokers. No outcome difference was found between the 2 conditions during the 1-year follow-up. (The combined 1-year abstinence rate was 61%, with 34% continuously abstinent.) The frequency with which participants used the device predicted both posttreatment coping skill use and smoking rate. Most notable was an interaction between treatment condition and negative affect. Provision of the devices negated or reversed the usual association between negative affect and poorer outcome.

Measures of affect and nicotine dependence predict differential response to smoking cessation treatments.

Smokers (N = 126) were randomly assigned to 6-session smoking cessation treatments consisting of 1 of 2 counseling strategies (skills training or support) and 1 of 2 nicotine exposure strategies (nicotine gum or rapid smoking). Counseling and nicotine strategies were completely crossed; all four combinations resulted in equivalent 1-year abstinence rates. Skills training produced higher initial cessation and more coping responses posttreatment than did support. Rapid smoking, but not nicotine gum, produced tachycardia to the taste of cigarettes posttreatment, consistent with cigarette aversion. The treatments were differentially effective among subpopulations of smokers: Subjects high in pretreatment negative affect responded best to support counseling; those low in pretreatment negative affect responded best to skills training. Self-reports of pretreatment craving predicted response to the nicotine exposure treatments.

Preventing relapse among former smokers: a comparison of minimal interventions through telephone and mail.

This study compared 2 minimal interventions for reducing relapse in ex-smokers. One intervention involved 12-month access to a telephone hot line. In the other intervention, 8 relapse-prevention booklets were mailed to participants over 1 year. The 2 interventions were crossed in a 2 x 2 factorial design, yielding control, hot-line-only, mailings-only, and combined conditions. The criterion of at least 1 week of abstinence at baseline was met by 584 participants, 446 of whom also completed a 12-month assessment. Repeated mailings, but not the hot line, reduced relapse for those participants who had been abstinent for less than 3 months at baseline. At follow-up, 12% of those in the mailings conditions were smoking again compared with 35% in the nonmailing conditions. As predicted, both interventions were effective at attenuating the association between depressive symptoms and poor outcome found in the control condition.

Introduction to the special section on empirical underpinnings of the ethics of alcohol administration in research settings.

This article introduces the special section of Psychology of Addictive Behaviors that focuses on the ethics of administering alcohol to human research participants, particularly those with a history of alcohol abuse or dependence. It is argued that many assumptions underlying ethical decision making can be put to an empirical test. These assumptions involve the degree to which participants can understand and give informed consent as well as the types and magnitude of possible risks associated with consuming alcohol in a research setting. The research literature relevant to these assumptions is reviewed in this series.

Reactivity to instructed smoking availability and environmental cues: evidence with urge and reaction time.

Reactivity to drug-related cues has been proposed as a possible mechanism to explain maintenance of drug use and relapse. This study examined whether cognitions associated with drug use (the belief that nicotine is available for use) also elicit reactivity. Smokers (N = 132) were randomly assigned in a 2 (Smoking Availability) x 2 (Smoking Stimuli) factorial design. Reactivity was measured by self-reported urge and probe reaction time. A main effect for availability was found in that participants who had been told that they could smoke shortly reported greater urges than those who had been told that smoking would not be permitted for 3 hr. Moreover, smoking-related stimuli produced increases in urge ratings only when participants had been told that smoking would be available shortly. Probe reaction time, in contrast, increased in the presence of smoking stimuli only when participants were told that cigarettes were unavailable. The theoretical and treatment implications of drug availability as a moderator of cue reactivity, as well as the utility of reaction time as an index if drug use motivation, are discussed.

Classical conditions of environmental cues to cigarette smoking.

Smoking-related cues tend to produce urges and cardiac responses in smokers. This reactivity has been assumed to reflect prior classical conditioning. However, little direct evidence exists supporting the notion that environmental cues can be classically conditioned to cigarette smoking. In this study, 8 smokers received 22 daily trials during which 2 cue complexes (comprising visual, olfactory, and auditory stimuli) were paired with smoking (CS+ trials) and not smoking (CS- trials). Reactivity to the environmental cues, as measured by self-report of urge and pulse rate, increased across CS+ trials, diverging from responses in the CS- trials. Reactivity was stronger among light smokers and those who verbalized awareness of smoking contingencies. Findings indicate that environmental cues can be classically conditioned to smoking.

Testing the causal role of expectancies in smoking motivation and behavior.

The causal role of outcome expectancies in smoking motivation and behavior was tested in a laboratory experiment. Two expectancy manipulations-Health Consequences Expectancy Increase (HC) and Mood Management Expectancy Challenge (MM)-were crossed in a 2 x 2 factorial design. One hundred twenty-three heavy smokers were randomly assigned to the conditions and shown videotaped interviews of smokers and exsmokers followed by an interview that personalized the information. Both manipulations produced changes in targeted expectancies on at least one of two expectancy instruments. As predicted, only the HC manipulation produced increases in motivation to quit smoking and a reduction in smoking 3 months later. This study provides initial evidence that smoking expectancies play a causal role in smoking motivation, consistent with previous research with alcohol.

Postcessation cigarette use: the process of relapse.

One hundred twenty-nine chronic smokers successfully completed a smoking cessation program composed of behavioral counseling and aversive smoking. During the two-year follow-up period, 92 of these subjects reported smoking. The progression from subjects' first cigarette to full relapse was examined via standardized telephone interviews. The latency between subjects' initial postcessation smoking episode and subsequent return to daily smoking was related to pretreatment confidence level, affective state at the time of the first cigarette, and origin of the first cigarette. Neither affective reaction nor coping response execution after the initial cigarette was related to the rate of relapse. Results are discussed in terms of current theory and treatment implications.

Very delayed smoking relapse warrants research attention.

Recent findings suggest that former smokers remain at risk for relapse well beyond the traditional treatment follow-up period of one year. Although progress has been made in understanding factors involved in smoking cessation and short-term maintenance, very little attention has been paid to research on the process, predictors, and treatment implications of very delayed relapse. Possible research questions are offered to stimulate further investigation in this area.

The increasing recalcitrance of smokers in clinical trials.

It has been suggested that a consequence of the declining prevalence of smoking in the United States over the past 25 years is that the population of remaining smokers is becoming more difficult to treat. That is, compared to smokers of years past, today's smokers are more likely to be highly nicotine dependent, have comorbid psychiatric and substance abuse disorders, have less education, and be of lower economic status. If this is indeed the case, there should be found declining abstinence rates in published clinical trials, when the type of treatment is held constant. To test this hypothesis, a literature search was conducted for group-administered multicomponent smoking cessation trials that emphasized coping skills training. Twenty-three studies published between 1977 and 1996 were identified. As predicted, robust negative correlations were found between year of publication and end-of-treatment abstinence rates. Using point-prevalence abstinence rates from later follow-up points produced somewhat weaker associations. Controlling for the use of biochemical verification or nicotine replacement therapies did not alter the findings. In summary, the efficacy of clinical trials--with treatment held constant--appears to be declining. One possible cause is the increasing recalcitrance of those individuals who continue to smoke despite social, regulatory, and medical pressures to quit.

Contemporary smoking cessation.

BACKGROUND: Tobacco smoking is the single most preventable cause of death in the United States today. Oncologists are in a unique position to affect the health and economic burdens of smoking by encouraging cessation among their patients who smoke. METHODS: The authors describe and review the effectiveness of current smoking cessation interventions as well as strategies that can be used to encourage cessation among patients. Three types of smoking cessation interventions are described: minimal (or self-help) interventions, behavioral interventions, and pharmacotherapy. The effectiveness of combinations of these types of treatments is also discussed. RESULTS: Oncology professionals can improve their patients' chances for success by implementing various cost-effective and easily executed smoking cessation interventions. Advice from a physician to quit smoking has resulted in long-term quit rates of up to 10.2%, and nicotine transdermal patches, nicotine gum, inhalers, and nasal sprays are also effective. CONCLUSIONS: Oncologists are encouraged to adopt the "4As" treatment protocol recommended by the National Cancer Institute: ask patients about their smoking status, advise them to quit, assist by recommending pharmacotherapy, counseling, and psychosocial self-help materials, and arrange follow-up.