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Tobacco Dependence: Treatment Behavioral Solutions for Quitting
Tobacco Dependency continuing education counselor CEUs

Section 13
Cognitive Counter-Conditioning for Tobacco Dependent Clients

CEU Question 13 | CEU Test | Table of Contents | Addictions
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

For some time now, psychologists have been developing theories around how health behavior change can be effected. For example, the stages of change approach is now widely utilized in the field of health promotion (DiClemente & Prochaska 1982, DiClemete 1986). This is the notion that in changing any behavior, people progress through a sequence of stages, from initially having no desire for change, through to planning change actively and putting the plans into action. A very positive point which emerges from this approach, if it is shared with smokers during an intervention, is that it reinforces the need to make active plans around attempting to stop. Another very successful notion in the area is self-efficacy (Bandura 1977), which in simple terms is the idea that our confidence in our abilities to carry out some action will largely determine whether we engage in that behavior, so that smokers will only attempt to quit smoking if they believe that they have a reasonable chance of success. Hence this construct is a very good predictor of which smokers are likely to make an attempt to stop smoking (Condiotte & Lichtenstein 1981). Further, notions of how smokers might attempt to counter condition their habit have been applied (Marks et al. 2000). This is the attempt to use self instruction training to counter attitudes, by having smokers rehearse the negative aspects of smoking in order to reinforce a negative attitude and counter any positive views. This study set out to evaluate the extent to which these various psychological insights can be applied to provide a coherent framework within which smoking cessation interventions can be based. The intention was to demonstrate how smoking cessation workers can adopt a thorough intervention strategy which includes well established NRT (Nicotine Replacement Therapy) techniques but also utilizes current psychological insights successfully. A full account of how such an approach can be applied can be found in Ward (2000).

The aim of the current study was therefore to determine the success of an approach to smoking cessation based upon NRT with the addition of three key psychological techniques. The first of these is outlining to smokers the notion of stages of change (SoC) (DiClemente et al. 1985) so that they can evaluate their own progress and gain perspective on what they need to achieve. Stages of change is now a widely accepted concept, which has been shown to be relevant to smokers trying to stop smoking (DiClemente et al. 1991). The second is to help smokers evaluate their current state of self-efficacy (SE) for smoking cessation so that they gain insight into their state of readiness for attempting to stop smoking. Self-efficacy has been shown to be a successful predictor of success in smoking cessation (Garcia et al. 1990). The third is to teach smokers a cognitive counter conditioning (CCC) technique, which they can apply every time they light a cigarette and which will in theory reduce their pleasure in the habit over time as they continue to practice the technique. Similar, but less thorough, procedures have been used with success in the past (Marks et al. 2000). These three insights will be further explained in the methods section, but a full account and the means of implementing them can be found in Ward (2000). It was hypothesized that the key psychological technique to be used was the counter conditioning procedure, as this would effect change in the smokers attitudes, whereas the other techniques would only increase insight. For this reason it was decided to compare two conditions in the study. The first consists of NRT plus the first two techniques, whilst the second condition consisted of NRT plus all three techniques. Thus the main point of contrast in the study is whether volunteers were exposed to the cognitive counter conditioning technique. It was hypothesized that the success rate would be greater in the second condition, that is, NRT plus the three techniques including counter conditioning, with NRT minus the counter conditioning technique serving as the control. The outcome measure was abstinence at 6 and 12 months post intervention, with saliva cotinine analysis used as a check on self reported abstinence. Measures of self-efficacy and attitude towards smoking [measured using the pros and cons scale reported in Velicer et al. (1985)] are also reported to support suggestions as to the mechanisms of change taking place in smokers as they move towards abstinence.

Each treatment group met in a group session for three 2 hours sessions over a 3-week period, with a further 2 hours follow up meeting 1 month later. The sessions took place in a venue where smoking was permitted, and volunteers were allowed to smoke during the sessions (in fact this was an important aspect of the counter conditioning technique). During the sessions the volunteers were guided through the following techniques. Volunteers were followed up 6 and 12 months later by attendance at follow up meetings or in a few cases home visit or telephone.

NRT: The various types of NRT were explained, and samples were examined of patches and gum. Some non-NRT remedies were also examined, though it was suggested that the efficacy of these was less certain. Volunteers discussed their preferences, past experiences and future intentions.

Stages of change: The various stages of change were outlined, and volunteers completed a short questionnaire to identify which stage of change they were at. The stages are: Pre-contemplation -- not thinking of stopping smoking in the near future.  Contemplation -- thinking of stopping, but not actively planning to stop in the near future.  Preparation for action -- planning to stop quite soon, i.e. in the next month.  Action -- actually abstaining and planning to remain abstinent.
Maintenance -- having been abstinent for at least 6 months.

The implications of this, and what was required for progress was discussed as a group. In particular the preparation for action stage was highlighted, and the need for adequate planning to manage situations and problematic events outlined.

Self-efficacy: The notion of self-efficacy was explained to volunteers, and they completed a questionnaire to assess their self-efficacy for smoking cessation. The use of this information as a guide to readiness for an attempt to stop smoking was discussed. Thus volunteers were able to judge how confident they were that they might be able to stop smoking and were asked to set a tentative quit date based upon this information.

Cognitive counter conditioning: Volunteers first of all worked together as a group to produce rich negative schemas about smoking, for example, involving the effects on their health, cost, smell, etc. A schema can be thought of as a set of interconnected ideas, so the group eventually have before them a web diagram representing a particular negative aspect of smoking. They were then taught to rehearse mentally these negative schemas whilst actually smoking, to counteract the positive reinforcement of smoking and to develop a negative attitude towards the habit, which would be activated by the very process of smoking. It was emphasized that success would depend upon carrying out this procedure faithfully whenever the smoker indulged in the habit, making every cigarette a 'negative' one.

The 1-month follow up visit consisted of reiterating the above information, reviewing progress (including a further administration of the SE scale), discussing experiences across the group and making definite commitments to action for the next 5-month period to the first outcome point. At 6 and 12 months, volunteers were again invited to attend a short follow up meeting, which followed a similar agenda to the 1 month visit outlined above with the addition of a determination of smoking status and collection of saliva samples. Non attendees were followed up via telephone and individual appointments.

This study has shown how workers can carry out successful smoking interventions based on the widely accepted techniques of NRT but which include additional insights from psychology. These techniques can be used to build a framework within which group interventions can take place, giving points for discussion and mutual support. The success rates achieved in terms of 6 and 12 month abstinence rates are very respectable for this type of work, particularly for treatment B which achieved 32% abstinence at both 6 and 12 months. Treatment A started well with a 6-month abstinence rate of 25%, but this declined to 17% at 12 months. These figures for treatment A are in line with those typically found with NRT alone. For example in a thorough review of 70 studies Silagy et al. (1994a) found rates of up to 23%, with rates below 20% being more typical. In this context it can be seen that the rate for treatment B of 32% is impressive, although there proved to be no significant difference between conditions A and B. This may be a reflection of sample size rather than a genuine lack of increased efficacy in respect of condition B. On examination both treatments were found to have increased the rate of abstinence from smoking significantly higher that that observed in the waiting list control condition. Thus both interventions were effective aids to smoking cessation.

Although the very encouraging abstention rate observed in condition B did not prove significantly different to that for condition A, there are signs in the other variables examined that the counter conditioning technique is a worthwhile long-term strategy. This is because the volunteers in condition B who were exposed to the counter conditioning technique were also found to have increased self-efficacy in both abstainers and smokers, which suggests that confidence in being able to quit was moving in the right direction in all the participants, and it would be interesting to follow up smokers exposed to this technique over a longer term to see if self-efficacy continues to increase and whether this further increases abstention rates. This finding for the self-efficacy variable adds some support to the original suggestion that the cognitive counter conditioning technique would be the key psychological aspect of the study. Pros and cons scores moved in the expected directions across both treatment groups, with those smokers able to achieve abstention rating their feelings about smoking as less positive and more negative.

This study has shown that psychological theories can be used to structure smoking cessation interventions and that such an approach is highly acceptable to participants. A cognitive behavioral approach together with nicotine replacement and guidance as to preparation for abstinence proved most successful, achieving one year abstention rates above those typically reported for nicotine replacement alone and significantly above the rate of abstention occurring spontaneously in waiting list controls.
- Ward, Tony ; Using psychological insights to help people quit smoking;  Journal of Advanced Nursing; Jun2001; Vol. 34 Issue 6

Personal Reflection Exercise #6
The preceding section contained information about cognitive counter conditioning for tobacco dependent clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 13
 What were four focus areas in Ward’s smoking cessation intervention strategy? Record the letter of the correct answer the CEU Test

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