ATTUD Journal Club Postings

Another New Behavioral Treatment for Tobacco Dependence

For many years there was a dearth of research on new behavioral treatments for tobacco dependence, but recently we have had several; e.g., Mindfulness therapy (MT), Acceptance/Commitment Therapy (ACT), Behavioral Activation Therapy (BAT) , Positive Psychotherapy(PP) and Contingency Management (CM). One other possible new treatment that has yet to be formally tested is manipulating behavioral substitutes and complements‐two constructs developed from Behavioral Economics Theory. Substitutes are behaviors that compete with smoking and thus decrease smoking (e.g. being around a good friend who does not smoke). Complements are events that are associated with smoking (e.g., taking a break at work). A recent analysis had smokers monitor a list of 45 possible substitutes and complements during a clinical smoking cessation trial (Drug Alcohol Depend 138: 67‐74, 2014). The study also had them monitor depression symptoms. Smokers who successfully abstained increased substitutes and decreased complements during the quitting process. Although it is possible that stopping smoking caused the changes in substitutes and complements, a more logical explanation is that changes in substitutes and complements helped smokers remain abstinent. One could hypothesize that the efficacy of changing these events was due to their decreasing post‐cessation depression, but that did not seem to be the case. I know of no experimental test of actually increasing.

A similar, but different, treatment called Community Reinforcement Approach (CRA) focuses on identifying reinforcers for abstinence and for sobriety. It has been used successfully for alcohol and cocaine dependence but has not been tested for tobacco dependence. Another similar approach, called Behavioral Activation Therapy (BAT), assumes smoking cessation produces some depression and anhedonia (i.e. loss of interest in or pleasure from events). This notion is consistent with animal data that nicotine makes rewards even more rewarding and that abstinence makes rewards less rewarding. These two outcomes (depression and anhedonia) are assumed lead to smokers not engaging in rewarding events. Thus BAT aims to have patients sample reinforcers to try to reinstate rewards, especially those that might compete with smoking.

Perhaps we will end up with new cognitively‐oriented therapies (MT, ACT, PP) for the more “psychologically minded” smokers, and new behavioral treatments (CRA, CM and BAT) for those who are less psychologically minded (who perhaps need to see behavioral successes). Discoveries require both intelligence and persistence.