Why is it so Hard to Quit Smoking?

The facets of addiction and their psychological treatments.

Author: Farah Gala
Editor: Gracie Enticknap
Artist: Mei-Ann Sim

In recent years, the global campaign against smoking has successfully made the negative health effects known on a wide scale. Yet, a significant portion of people continue to smoke due to a range of chemical and psychological factors. Smoking is one of the most widespread preventable causes of death and illness across much of the world, yet even when smokers are informed of the risks involved in smoking they can find it challenging to quit. Although it is widely known that cigarettes are addictive because they contain nicotine, there are far more factors to cigarette addiction than simply chemical addiction to nicotine. This is the story of how we get addicted to cigarettes, and what can be done psychologically to quit addiction. 

The first reason it’s so hard to quit smoking is due to the addictive property of nicotine which reinforces the act of smoking. Additional risk factors for picking up smoking include certain personality factors such as risk-taking behaviour and rigid thinking. Quitting the habit is also made more difficult due to any predisposing factors such as stress or trauma which a person may experience before beginning the habit of smoking.  This is a common finding through many addictive and damaging repetitive behaviours. 

Cessation methods often do not address the underlying causes of why a person began and continues to smoke. For example, having existing mental health issues can make the task of quitting smoking even more difficult, and can make people less likely to attempt quitting. It can also make one feel a lack of control, which can lessen confidence in the probability of successfully quitting. In order to target specific roadblocks which might impede cessation, several therapeutic modalities have been designed, two of which are positive therapy and acceptance and commitment therapy (ACT). The common link between these, and therefore something which makes them effective, is targeting the core beliefs behind someone’s smoking habit. 

Nicotine activates dopaminergic receptors in the ventral tegmental area involved in reinforcing rewarding or pleasurable activities; this establishes a strong motivational drive to smoke. It is one of many positive reinforcers associated with smoking. Constituents to cigarette smoking act as further reinforcers for the behaviour, such as the action of lighting and smoking it, the smell, and the “feeling in the lungs”, as described by current smokers. There is additionally the social component to the activity, as smoking could be an easy way to meet and interact with people. Denicotinized cigarettes reduce cravings and withdrawal symptoms even though they don’t have the active addictive ingredient. This indicates that blood nicotine level is not the only addictive aspect, but that the process of administration also plays a part

Personality factors also play a role in how addictive one finds smoking. Risk-taking was one of the first identified factors which increased the preponderance of smoking, and reduced concern about the health detriments associated. Studies using gambling tasks have found that the tendency to yield short term gratification was more represented in smokers. Smoking is also associated with other behaviour factors such as impulsivity, psychoticism, disinhibition, experience-seeking, boredom susceptibility, negative affect, and sensation seeking. A person ranking highly on sensation seeking might be more sensitive to the stimulating reward of smoking, thus making them more vulnerable to becoming dependent. High negative affect is also a predictor of low success of smoking abstinence among those attempting to quit; it lowers motivation to make healthy changes. This is also seen on a larger scale, in dysfunctional social environments. Unsurprisingly, this is not exclusive to smoking; high negative affect reduces rates at which successful change is made for a range of negative lifestyle choices. Positive therapy, a humanist psychodynamic psychotherapy, is one method that helps decrease negative affect and increase successful cessation.

Positive therapy seeks to maximise the good rather than just minimize the bad. It is rooted in the more personal and empathetic humanist therapies, which often denounce the clinical way many mental disorders are treated by more traditional therapies. It focuses on positive life influences, experiences, and personal traits. This shifts focus away from the mental blocks and environmental factors that maintain smoking to the positive traits that one possess and positive social and environmental supports which could aid in cessation. One particular study integrated nicotine replacement therapy, generic smoking cessation counselling, and positive psychology interventions. Attendance rates were high, and more than half reported a benefit from the positive psychology interventions. More specialized studies, without simultaneous implementation of other therapies, would be helpful in discerning positive therapy’s viability on its own. Another study suggests that positive therapy may be beneficial as opposed to traditional CBT (cognitive behavioural therapy) because CBT attunes participants to the presence and recurrence of negative moods which often arise during treatment. Finally, other studies have suggested that CBT and mood management may increase negative moods and depressive symptoms during smoking cessation treatment. 

CBT holds the assumption that humans are psychologically healthy by nature; ACT on the other hand assumes that mental processes can often encourage destructive behaviours such as smoking. This is attributed primarily to avoidance behaviours and rigidity of thinking, as they prevent positive behaviour changes. Correlational studies have identified rigid thinking as a risk factor for many psychopathologies. Throughout treatment, clients learn and are encouraged in processing thoughts, feelings, memories, and sensations which have been feared and avoided. Through this, they are more able to confront which innate beliefs are preventing successful cessation. Ideally, they also learn to recognize and avoid situations in which these negative behaviour patterns often arise, which helps to work towards cessation consciously. The ideal therapeutic outcome is that slowly learning how to deal with negative thoughts leads to better skills in assessing enabling thoughts, emotions, and situations surrounding the urge to smoke.

From the perspective of ACT, a smoker’s attempts to avoid unpleasant sensations (e.g cravings and withdrawal symptoms) often lead to a reduced ability in taking action. Confronting unpleasant sensations allows for internal goals and motivations (e.g the commitment to quit) to guide behaviour. ACT provides a foundation from which smokers can assess their thinking patterns, notably the avoidance of unpleasant associations, which may be preventing successful cessation. This can be beneficial for certain risk factors associated with smoking, such as boredom susceptibility, as it can help build goals to prevent destructive behaviour (e.g smoking). However, other factors such as impulsivity and psychoticism have a strong genetic factor. The self-directed and liberal structure of ACT is therefore not conducive to confronting these impediments to cessation.

In summary, preexisting mental vulnerabilities make smoking difficult to quit for many people; effective therapies ought to target these underlying problems. Nicotine replacement therapy is a helpful tool to stave off withdrawal symptoms during treatment. Positive therapy does not focus on the negative effects of quitting, rather, it helps patients recognize beneficial skills which they possess which can help them quit. This helps reduce the deleterious influence of negative affect, which can be worsened by symptom tracking, on cessation efforts. ACT allows individualized reflection of which thought patterns are preventing a change in behaviour. It also encourages people to acknowledge and confront their fears surrounding cessation. This may be more effective than suppressing and ignoring cravings, as avoidance behaviours may be an enabling factor for harmful habits. A drawback of both ACT and positive therapy is that they do not address how genetic factors, either inherited psychopathologies or predispositions to addiction, contribute to the maintenance of the habit. In sum, it is difficult to define one method of facilitating smoking cessation, as each person’s difficulties with quitting are personal to them. The best course of treatment is a combination of treatments that are adjusted and evaluated according to an individual’s needs. A focus on deeper psychological factors driving the behaviour is likely more beneficial than a focus on minimizing overt unpleasant symptoms of smoking cessation. Human behaviour is often illogical, destructive, and difficult to find the root cause of, smoking is no exception. 

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