Addicted to Nicotine
A National Research Forum

Section VI: Treatment of Nicotine Dependence
John Hughes, M.D., Chair

PSYCHOLOGICAL INTERVENTIONS

Sharon M. Hall, Ph.D.
Department of Psychiatry
University of California at San Francisco

Introduction

For years, it has been agreed that psychological interventions that include the monitoring of smoking behavior within a structured program, as well as an emphasis on motivation, improve abstinence rates. Current questions address more complex issues. Among the most salient of these questions are the following: (1) Are specific interventions developed for defined diagnostic groups more effective with those groups than with those developed for the general population? (2) Are there methods of partitioning smokers, other than diagnostic groups, that provide a useful basis for developing targeted psychological interventions? (3) Do psychological interventions increase abstinence rates when added to pharmacological therapies? (4) What new therapies should be developed?

What We Know

Three kinds of psychological intervention are used in smoking cessation treatment: psychoeducational interventions, behavioral skill training, and cognitive-behavioral interventions. Psychoeducational approaches include information about smoking and health, information about strategies for quitting and maintaining abstinence, and group discussion to further understand and implement these changes. Behavioral skill training includes behavioral prescriptions, such as monitoring smoking situations, and practicing skills in the treatment setting and in the natural environment. Examples are rehearsal of cigarette refusal skills and relaxation practice. Cognitive-behavioral interventions include changing thoughts about smoking and quitting smoking and related situations and emotions. Treatment programs often include a combination of these three intervention types.

• Matching Treatments to Diagnostic Groupings. There has been progress in matching patients to treatments. Specific populations with high smoking rates have been identified, including psychiatric patients, especially those with depressive disorders or psychosis, and patients with alcohol and other drug disorders. Smokers with major depressive disorder (MDD) have been the most extensively studied. For example, data indicate that smokers with a history of MDD were more likely to quit smoking in a cognitive-behavioral intervention than in a control psychoeducational intervention, but only when the psychoeducational intervention provided fewer contact hours than the cognitive-behavioral intervention.

  These data suggest that increased therapeutic contact is helpful for smokers with a depression history. More than one therapeutic approach may be useful, and the best therapeutic content needs to be determined. Mechanisms of action underlying the increased effectiveness of more intensive, supportive treatments with depressed smokers have been suggested. Possibilities include increased or better sustained motivation or less increase in the poor mood that frequently accompanies quitting smoking.

• Matching Interventions to Special Subgroups of Smokers. Some data suggest that smokers differ widely in readiness to quit. These data are especially relevant to smokers diagnosed with substance abuse or psychiatric problems, since such samples probably contain a relatively high proportion of smokers who are not ready to enter a traditional treatment program for smoking cessation. Such programs usually require a high and sustained degree of motivation to quit.

  Other data show that psychological interventions can be successfully tailored to the individual smoker's readiness to quit. Computerized expert system interventions have been developed that are targeted at a smoker's self-professed level of interest in quitting, which may range from precontemplation, a stage at which the smoker has no interest in quitting, to contemplation, to preparation for action, to action itself. In at least one study, expert systems developed by this group have shown efficacy in increasing readiness to quit and improving abstinence rates.

• Psychological Interventions and Pharmacotherapies. There is considerable evidence that combining psychoeducational or behavioral skill training interventions with nicotine replacement increases the abstinence rates found when smokers quit using nicotine replacement therapy alone. Several mechanisms have been suggested to explain this effect.

In summary, the following facts are known:

• In treatment-seeking smokers, psychological interventions for smoking cessation are more effective than no treatment.

• For at least one category of comorbid smokers, those with depressive disorder, psychological interventions increase abstinence rates.

• Psychological interventions targeted to smokers who express a readiness to quit increase abstinence rates in samples of smokers who have not yet made a commitment to abstinence.

• Psychological interventions increase abstinence rates when combined with nicotine replacement therapies.

What We Need To Know More About

Matching Treatments to Diagnostic Groupings. Data are lacking on psychological interventions with schizophrenic or psychotic patients. There are also few data on the usefulness of psychological treatments in alcohol- or other drug-abusing patients who smoke. Treating smokers who are already in recovery programs for nonnicotinic drugs may require less psychological intervention than is required for smokers who are not in recovery treatment. Much of the content of the treatment interventions offered for other drugs of abuse may easily generalize to cigarette smoking. This is speculative, and data are needed.

Matching Interventions to Special Subgroups of Smokers. More work is needed to develop successful interventions for smokers who have not yet made a clear commitment to quit. Current work is promising, but unique interventions designed to overcome the special barriers to quitting that plague special populations are needed and should be tested in rigorous, controlled trials by a variety of research groups. Because smokers not ready to quit may resist face-to-face interventions, development of other treatment modalities, for example, computerized interventions, is needed.

Psychological Interventions and Pharmacotherapies. We do not know whether psychological therapies increase the efficacy of antidepressant therapy for nicotine dependence. There are two large studies of successful antidepressant therapy of cigarette smoking. One used extensive psychological interventions; the other did not. Outcomes of the two studies were similar, although it is not possible to compare the studies. There are many crucial differences between them other than the provision of psychological intervention, including differences in the antidepressant drug used and in sample characteristics. Additional research is needed to determine whether the combination of psychological interventions with antidepressants increases abstinence rates, and if so, by what mechanism.

New Therapies. The field of late has been slow to develop new interventions based on psychological principles, instead turning its attention to issues of cost and cost-effectiveness and degree of generalizability. Nevertheless, at least one promising new therapy - scheduled reduction - has been assessed and its effects replicated. On the other hand, given the diagnostic, cultural, and motivational heterogeneity of smokers today, it is likely that many forthcoming innovations will be targeted to specific subgroups of smokers.

The following questions represent areas of research required to more fully elucidate the relationship between smoking cessation and psychological interventions:

• Given that psychological interventions increase abstinence rates in smokers with depressive disorders, which interventions are the most efficacious?

• By what mechanism do psychological interventions increase abstinence rates in smokers with depressive disorders?

• Which psychological interventions, if any, are useful for smokers with other psychiatric and substance abuse disorders?

• Can interventions for smokers who are not yet ready to quit be developed that are widely applied and useful with special populations and subgroups?

• Do psychological interventions increase abstinence rates obtained with antidepressant drugs, and if so, is there an optimal intervention?

• Should efforts to develop new psychological interventions be targeted to smokers in general or to specific subgroups?

Recommended Reading

Cinciripini, P.M.; Lapitsky, L.; Seay, S.; Wallfisch, A.; Kitchens, K.; and Van Vunakis, H. The effects of smoking schedules on cessation outcome: Can we improve on common methods of gradual and abrupt nicotine withdrawal. J Consult Clin Psychol 63(3):388-399, 1995.

Hall, S.M.; Reus, V.I.; Muñoz, R.F.; Sees, K.L.; Humfleet, G.; Hartz, D.T.; and Triffleman, E. Nortriptyline and cognitive behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry, in press.

Prochaska, J.O.; DiClemente, C.C.; Velicer, W.F.; and Rossi, J.S. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psychol 12(5):399-405, 1993.