Although many bemoaned the lack of innovative behavioral therapies for smoking in the 1990s, recently there has been a spate of new treatments‐mindfulness, acceptance therapy, persistence therapy, etc. These new treatments have often arisen from basic psychology theories that have been validated. One of these is the “Strength Model of Self‐Control” that posits one has a limited amount of self‐control and expending self‐control in one area, depletes this resource and, thus, one has less self‐control to tackle a new problem in a different area. A meta‐analysis of 83 tests of this theory found consistent support , including studies examining smoking (Hagger, Psych Bulletin 136: 495, 2010). More recent studies have suggested this effect is due, in part, to the person’s expectancy that willpower will be diminished after exerting self‐control (Job, Psychol Sci 21:1686, 2010). They also suggest that although expending self‐control on an earlier single task immediately decreases later self‐control, this effect wears off after repeatedly dealing with the earlier task (Dang, Conscious Cog 22:816, 2013). And some are even coming up with treatments to decrease the adverse effects of expending self‐control (Schmeichel, J Pers Soc Psycho 96:770, 2009).
This work has many important implications, but the one that intrigues me is what it suggests when a person wants to change several behaviors. Consider the heart attack victim who needs to change his activity levels, medication compliance, diet, weight and smoking. The above model suggests he/she should not try to tackle all at once. On the other hand, since the above behaviors are often linked, they might be easier to tackle all at once (Prochaska, Prev Med 46:281, 2008). But there is amazingly little research on this. In terms of smoking, some early studies suggested dieting when trying to quit undermined the ability to remain abstinent, but later studies have challenged this. Also, although several studies suggest stopping smoking does not threaten alcohol sobriety, several studies have challenged this as well.
So what should the clinician do? I think “first things first;” i.e., what is the most important behavior to change in the short term and lets focus on that (and sometimes the patient and the clinician disagree with on which is the more important‐but here I believe in “the customer is always right” rule). I also think that, in the absence of convincing data, if someone wants to tackle two things at once, let’s let them do that, but warn them this may be difficult and if they have to give up one, it should be the less important one.
Look forward to hearing thoughts on this.