Three Emerging Trends in Smoking Cessation

Quitting smoking can be extremely difficult. This is because one of the main ingredients, nicotine, is a highly addictive substance – just as addictive as the illegal drugs heroin and cocaine.

As smoking is the leading cause of lung cancer, finding ways to help smokers drop the habit is vital to decreasing deaths from this disease. Strategies, tools, and techniques for quitting have increased and evolved over the years. For example, the development of nicotine replacement therapies – the patch, inhaler, and gum – has been one of “the most important breakthroughs,” according to Lee Westmaas, Ph.D., director of tobacco control research at the American Cancer Society and an expert in the field of smoking cessation.

Despite advances in smoking cessation, many smokers struggle to quit. Researchers and other professionals continue to look for and create new ways to help smokers stop. Two of the top emerging trends in smoking cessation are smartphone apps and new behavioral techniques.

A third trend in smoking cessation is the use of e-cigarettes. This trend, however, has been more consumer-led and researchers are now trying to determine the safety of the products themselves and whether they can actually help smokers quit.

Below is a review of these three major trends and expert insights from Westmaas into their salience for stopping smoking.

1. Smartphone apps: There are at least a few hundred smartphone apps geared toward helping smokers quit. Some of these apps simply give smokers tips for quitting, while others allows users to create a more customized approach – tracking their habits and connecting them with a support community. How helpful these apps are, though, is still an open question.

Westmaas: That’s right. As you can imagine, with the hundreds of apps available to smokers, the range of functions they provide can vary wildly. For example, some apps perform just a tracking function, others are hypnosis apps (which is not a proven quitting strategy), while others are more comprehensive in that they try to provide more evidence-based functions (e.g., by discussing quitting medications, or providing the free national quitline number, etc.).

Unfortunately, some of the most comprehensive apps may not show up first in the search for quit smoking apps (which we discovered during our last review of quit smoking apps), so smokers may not always know easily which ones have the best chances of helping them. Complicating matters is that there hasn’t yet been any published data on the effectiveness of apps for quitting (none using a randomized controlled design, which is the gold standard for determining efficacy).

There is scientific evidence, however, that texting programs that provide daily tips for quitting are effective, so to the extent that an app can provide a similar function, its ability to help smokers quit should be promising. Apps that include this and other evidence-based strategies for quitting include the NCI’s QuitPal app, the LiveStrong app, and the Quit for Life app from Allere Wellbeing.

In contrast to apps, we do have evidence that computer or Internet programs for smoking cessation can be effective. While they may not increase quit rates to the same extent as the most effective cessation strategy (medication combined with in-person behavioral counseling), the fact that they can reach so many smokers because of their accessibility through the Internet means they have the potential to significantly influence quit rates at the population level. Notable examples are the programs available through smokefree.gov and BecomeAnEx.org.

2. E-cigarettes: These cigarette look-alikes deliver vaporized nicotine to smokers. While not strictly marketed as a stop-smoking device, researchers are aggressively studying whether they can be safely used in this manner. E-cigarettes, however, are highly controversial.

Westmaas: Indeed. The topic of e-cigarettes as a cessation tool is a controversial one, and many in the scientific community have different opinions about it. At the present time, we don’t have any solid, methodologically sound evidence that they help smokers quit at higher rates than currently FDA recommended medications (such as nicotine replacement therapy, Zyban, or Chanix), or behavioral treatments such as telephone counseling.

One of the concerns is that smokers who might otherwise have been motivated to quit tobacco completely will simply switch to e-cigarettes because of the lower levels of toxicants associated with e-cigarette vapor compared with regular cigarette smoke. We don’t know, however, the long-term risks of inhaling the combination of chemicals typically found in e-cigarette vapor, particularly from the various types of flavoring users include in their e-liquids.

Also, because there is not yet legislation regulating these products, there can be wide variability in the levels of nicotine they provide. There may also be a risk from the components of the e-cigarette themselves. For example, one study found higher levels of silver and nickel in e-cigarette vapor than in cigarette smoke, which they believe leached from the cartridge/atomizer.

Because e-cigarettes mimic the feel and sensation of smoking some smokers may prefer to try them to quit smoking cigarettes, especially smokers who are resistant to using approved cessation medications. Only additional well-conducted research will tell us whether this strategy can be successful for the majority of smokers. The ultimate goal, however, should be to quit tobacco completely, at least until we know what the long term risks of e-cigarettes may be.

3. New behavioral techniques: Researchers are constantly looking for new ways to tap into smokers’ own minds to help them kick their habit. For example, a recent study by Westmaas and others found that engaging in new and exciting activities that are “self-expanding” may help smokers resist their nicotine cravings.

Westmaas: Yes this study was triggered by previous research in which we found that successful quits were associated in time with a higher number of events that could be considered to be very personally rewarding (such as starting a new relationship, or beginning a new academic or work career), or what we call “self-expanding.” Such events are characterized as novel, exciting, and challenging. We followed this up with studies in which we used fMRI (brain imaging technology) to examine smokers’ brains while we got them to think about or engage in self-expanding experiences. We found activations in areas of the brain associated with the experience of pleasure or reward, and deactivation in areas of the brain associated with cravings. One implication of the results is that smokers can use such experiences as a prime time to try to quit (e.g., if starting a new relationship), or to purposefully try to create events like these to coincide with quitting (e.g., starting a new hobby, beginning an exercise regimen).

Other new models of behavioral treatment for smoking cessation are also being studied. Acceptance-based therapy aims to help smokers better understand and accept negative feelings, rather than avoid them, because such feelings are often the triggers for smoking. Essential goals of this treatment are to help smokers gain control of negative feelings, separate the act of smoking from thoughts, feelings, and sensations that trigger smoking, and help smokers clarify their life values, barriers, and goals.

Mindfulness, either separately or as part of acceptance-based therapy, entails a focused awareness of sensations, minute by minute, during craving episodes, and to be accepting and non-judgmental of them. With practice, the goal, over time, is for smokers to unlink cravings with smoking.

Evidence for these strategies has shown promise. One study found that an acceptance and commitment therapy (ACT) treatment led to a 1-year abstinence rate (staying away from smoking completely) of 35% compared to 15% for nicotine replacement therapy. More research is needed to evaluate these therapies, to determine for whom they may be most effective, and how they can be disseminated more easily to the general population of smokers, for example in the form of apps or computer programs.

Bottom Line

While researchers continue to investigate these newer avenues for helping smokers quit, there are existing strategies and available tools that have been proven effective that smokers can use now. These include support groups, nicotine replacement therapy, prescription drugs, and toll-free quit lines.

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