Kicking the Habit for Good: Cognitive Behavioral Therapy for Smoking Cessation by Dr. Christopher Harte
Cigarette Smoking: Facts and Figures
Approximately one billion people worldwide are cigarette smokers, including 1 out of every 5 Americans (1). Smoking kills more than 5 million people worldwide each year (2), and is the single most preventable cause of illness and death in the U.S. (1, 3). It is estimated that one third of smokers make an attempt to quit each year, typically without any professional assistance.
Of smokers who quit on their own, fewer than 3% are successful in becoming permanent ex-smokers (4). Many smokers find it incredibly difficult to kick the habit and often feel discouraged and pessimistic about ever being able to quit for good. The good news is that there are effective treatments that can greatly enhance your chances of successfully quitting.
CBT Can Help You Quit
It has been shown that cognitive-behavioral therapy (CBT), combined with a smoking cessation medication (such as the nicotine patch, nicotine gum, and Chantix®, for example), is quite effective for smokers who are motivated to quit (5). CBT is an evidenced-based psychological treatment that focuses on identifying and changing maladaptive thoughts, emotions, and behaviors that trigger, worsen, and/or maintain a range of problems (such as depression, anxiety, addiction, etc.). Because changing your smoking-related behaviors – and restructuring your thoughts related to smoking urges – is essential to quitting, CBT can effectively be applied to smoking cessation.
An intensive CBT program is typically composed of three phases: preparation, quitting, and maintenance (or relapse prevention).
Phase 1: Preparation
Many smokers wanting to quit may feel compelled to do so immediately. However, engaging in a “preparation” phase can significantly improve your ultimate quitting success. During the preparation phase of a CBT smoking cessation program, there are two main goals:
1.) Gaining awareness of your smoking behavior. Smoking may feel like an automatic habit, often occurring subconsciously. In order to be able to change your smoking habits, you must first gain a full awareness of them. By monitoring the time of day you smoke, the situation or environment you are in when you smoke, and moods experienced when smoking, you will start to understand your unique smoking patterns. In addition, you will be able to figure out common triggers for smoking that can be targeted during the quitting phase.
2.) Setting a target quit date. It is very important to set a firm quit date at the outset of the treatment program. The quit date is typically set between 2 to 4 weeks after you start treatment in order to give yourself time to prepare for quitting.
Phase 2: Quitting
1.) Managing smoking triggers. Once specific cues for smoking have been identified, you will actively break the links between these triggers and smoking in the following ways: by avoiding these triggers, by changing your daily routines, and by substituting activities in place of smoking.
For example, before your quit date you will want to remove all smoking-related paraphernalia such as ashtrays, lighters, and cigarette packs. This will help turn a smoker’s home into the home of a nonsmoker, which will reduce the availability of smoking while also reducing the number of triggers for smoking. You may also want to avoid “high-risk” situations for smoking.
For many smokers, this entails avoiding drinking alcohol, going to parties, or socializing with other smokers. It will also be important to change your daily routines in order to break the automatic links between daily activities and smoking. For example, you may benefit from taking a different route to work, changing the location of your break while at work, or altering your evening wind-down routines.
2.) Medication. Pharmacotherapy is an effective option to help reduce nicotine withdrawal symptoms after you quit. One of the strongest predictors of relapse is the intensity of your urge to smoke (6). Medications, like the nicotine patch, deliver a safe and controlled amount of nicotine to your body so that you can reduce the physical aspects of your addiction while you utilize CBT techniques to address the psychological aspects of the habit.
3.) Coping with triggers after quitting. No matter how much you prepare for quitting, you will likely experience smoking-related triggers at some point after you quit.
There are a number of CBT-oriented techniques that help you cope with your urges such as:
- Restructuring your thinking patterns related to smoking (for example, challenging the belief that smoking is the only activity that relieves stress)
- Identifying ways to stay busy (boredom is a common trigger to smoke)
- Increasing physical activity (exercise has been shown to reduce smoking urges (7) and to reduce weight gain associated with quitting (8))
- Managing negative mood states (stress and other negative mood states increase smoking urges (9))
- Coming up with alternate activities to keep your hands and mouth active (for example, eating healthy snacks, chewing gum, holding a pen)
- Relaxation training using breathing-based methods and muscle relaxation techniques
Phase 3: Maintenance
Unfortunately, most smokers who quit eventually resume smoking within several months. Therefore, learning relapse prevention techniques is critical to maintaining your smoking abstinence. One of the most important things to recognize is the difference between a lapse and a relapse. A lapse is a temporary “slip” or mistake, while a relapse is returning to regular smoking. CBT can help you understand how you evaluate a slip, and help you to learn from these experiences to better prevent them in the future.
Those who are interested in quitting smoking can check out the website of the Society for Research on Nicotine and Tobacco (http://www.srnt.org/resources/public.cfm) to start learning more about the health benefits of and available treatments for smoking cessation.
Dr. Christopher Harte, PhD
Assistant Professor of Psychiatry, Boston University School of Medicine
Staff Psychologist, VA Boston Healthcare System
Licensed Clinical Psychologist, Psychological Associates of Southeastern Massachusetts
Dr. Harte's clinical and research expertise includes assessment and treatment of behavioral health problems including nicotine dependence, sexual dysfunction, and weight management difficulties, as well as mood, anxiety, and stress disorders. Visit Dr. Harte's Website
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