ATTUD Journal Club Postings

Does Promoting Insight into Addiction Help or Hinder Smoking Cessation?

Oftentimes those addicted to drugs deny they are addicted. Methods to convince them they are, indeed, addicted (many of which are confrontational) to break down “denial” are common in the treatment of non-nicotine addictions. Randomized trials of breaking down denial as a treatment are not available. In fact, others have argued that emphasizing addiction undermines willingness to change (Chapman, PLos Med 2010 7:e1000216).

So what is the evidence? One early study (Eiser, Br J Soc Clin Psychol 16:329¬336, 1977) found alcohol users who acknowledged they were addicted were more likely to say they wanted to quit; however, a later study by the same author (J Beh Med 8:321-341, 1985) failed to replicate this finding. More recently, a national UK study found that those who said they were addicted were more likely to have had a recent quit attempt (West, Addiction 105:1867-9, 2010). Also, across many studies, endorsement of addiction is associated with greater treatment seeking (Shiffman Drug Alcohol Depend 93:121-131).

In contrast, those who believe emphasizing addiction undermines change, point to evidence that smokers who rate themselves as more addicted say cessation is more difficult, and have lower self-efficacy for quitting. This argument assumes that the endorsement of addiction causes less quitting. One alternate assumption is that the inability to quit causes an endorsement of addiction.

Although I can find no direct comparison, denial about addiction appears to be less for smokers than for those addicted to other drugs, perhaps because there is less stigma for nicotine addiction than other addictions. Also, I can find no interventions to prompt smoking quit attempts by increasing insight into addiction, other than some versions of motivational interviewing asking smokers about their conceptions of whether they are or are not addicted and the rationales for that conception

So my conclusion? First of all, most all smokers who show up at a treatment site acknowledge they are addicted, so the relevant group here is smokers who are not seeking treatment; e.g., those seen in a hospital consult. Some smokers say they want to quit because they do not like to consider themselves as addicts or feel out-of¬control of their behavior. Discussing this as a motivator might be helpful. But I think more importantly, many smokers do not seek treatment until they have tried to quit on their own many times and failed. Any way we can motivate them to seek treatment earlier will increase their chances of quitting when young and,thus, be more likely to avoid the risks of their prior smoking. So I think the best way to use insight into addiction is to convince smokers that some smokers “have bodies more addicted to nicotine” than others, the same way some depressed people “have brains predisposed to chemical depressions.” (And I sometimes bring out the genetics of smoking) For these smokers, quitting on their own can occur but is unlikely and, most importantly, using treatment should be seen as being health conscious, not as a crutch. I have also found discussing their views of whether everyone with alcoholism should be able to quit on their own. In other words, I think emphasizing addiction is helpful only if helps smokers to accept treatment.

Thoughts?