ATTUD Journal Club Postings

Choosing a Counseling Therapy

After many years of stagnation in improving counseling approaches for helping smokers stop, we have several new counseling treatments. Most prominent are a) Motivational Interviewing, b) Reduction in cigarettes/day, c) Mindfulness Therapy, and  Acceptance and Commitment Therapy. Randomized trials show that MI (Cochrane Review, 2015) and reduction in cigarettes/day (Cochrane Review, 2015) both increase quitting among those not ready to quit, and also among those already trying to quit (although there is some negative data for reduction in the later group). Mindfulness Therapy (Add Behav 69:27-34) and ACT (Drug Alcohol Depend 155:in press) are both as effective as existing treatments (e.g. behavioral therapies).

The interesting thing is how different, and even contradictory, these treatments are. For example, motivational interviewing states one should not didactically instruct patients or urge change, but the 5As clearly states one should request a commitment to quit. Also, cognitive behavioral therapy focuses on coping skills and focuses on changing behavior. Mindfulness and ACT do not focus on changing behavior but on accepting and distancing from urges. Also, ACT focuses on values, psychological flexibility, and other areas not directly related to smoking.  In contrast, drug abuse counselors emphasize a laser-like focus on drug use and not let the patient divert to other areas. On the other hand, an old study by Albert Stunkard, found that obese patients in psychoanalysis who improved had a much greater weight lose than those that did not improve – and weight loss was never discussed.

So what is a TTS to do? Well you could use the say you will pick and choose from the treatments as need be. But then how does one decide whether to directly encourage a quit attempt vs let the smoker decide to quit? Or whether to ask for behavior change or say, no need to change, just accept the cravings. Or how does one decide whether to encourage abrupt or gradual cessation?

So my conclusion is that I have none.