CBT To Quit Smoking

When I was designing the psychological “track” of our treatment program, selecting CBT as one of its elements was an easy decision. CBT is an abbreviation for cognitive behavioral therapy, which is one of the most effective approaches for the treatment of drug and alcohol problems. Using it for our quitting smoking program in Maryland and DC was consistent with our practice of applying to nicotine the same clinical interventions that have been helpful in treating other drug problems.

What I like about the CBT approach is that it can be easily explained to patients, who can quickly relate it to their own experience. It begins with how external objects and internal experiences become “triggers” for nicotine cravings and thoughts about using. This is followed by a predictable cascade of distorted thoughts and beliefs (referred to as “cognitions”) that result in dysfunctional behavior, specifically nicotine use. Over time this process becomes so automatic that the person does not notice its progress until out-of-control nicotine use is occurring.

Treatment begins by making patients aware of each of the cascading steps so that they are no longer automatic. As awareness of the steps increases, patients realize that their return to nicotine use is a process rather than an event. This insight “buys them time” to intervene earlier in the process and interrupt it before the step of actual use occurs. They begin to recognize the “early warning signs” of relapse.

Next, the patient learns to identify their personal triggers so that they can avoid them early in their treatment, or not be blindsided by them if they cannot be avoided. The result is a reduction in the impact of their cravings for nicotine. Finally, they examine the distorted nature of the thoughts and beliefs that have developed over the years of heavy use, and begin to replace them with more accurate cognitions.

Diagrams can be useful in explaining this process. I was very excited when I first encountered these ideas in the writing of Alan Marlatt and Aaron Beck. After changing some of the words to ones which I thought would be more compatible with the language used in the addictions field, I began showing to my patients a Beck diagram outlining the substance use process. They made some suggestions that made the diagram a little more complicated but which fit better with their experience. The result of our collaboration is the diagram you see below:

In the diagram, you can see why triggers and cravings are so important in starting the cascade. I added a preliminary “Set Up” step to cover those occasions when a person goes out of their way to encounter a trigger rather than be the passive recipient. Triggers set off both cravings and automatic thoughts, such as “A cigarette would certainly feel good right now.” This leads to the activation of more complex beliefs and then a permission giving rationalization such as “I’ll only have one.” Not until that stage of progression does actual use begin. 

During treatment sessions, we have the diagram available and identify the place that corresponds to the end of the patient’s narrative. We then work our way backwards to help the person understand the preliminary steps that led to that place. With experience and repetition, patients expand their list of triggers, realize that cravings are time-limited, and begin to challenge some of their own distorted beliefs. By interrupting the relapse process prior to actual use, abstinence is established and, over time, becomes more enduring. 

Background

CBT filled a vacuum for professionals by providing an organized psychological system and language that facilitated communications amongst themselves and with their patients. It referred to personal experiences which could be readily recognized by patients, as opposed to the language of psychoanalysis, which focuses on unconscious psychological processes beneath the surface. Aaron Beck, who was trained as a psychoanalyst, responded to criticism that his work was too superficial by saying “There is more to the surface than meets the eye.”

Important in making CBT acceptable to people in recovery is that it is compatible with the precepts of major groups in the recovery support community. For example, the secular support group SMART Recovery, explicitly describes itself as being “grounded in Rational Emotive Behavioral Therapy and Cognitive Behavioral Therapy.”

In addition, the thinking of 12-Step Fellowship programs has always focused on the importance of triggers. Members are frequently reminded to be aware of the danger of “people, places, and things” that were previously associated with substance use. They are also warned that being Hungry, Angry, Lonely, or Tired – the acronym “HALT” being frequently cited – are times when their recovery may be in jeopardy. Nicotine Anonymous is a 12-Step program specifically focused on nicotine use.