Form of CBT Helps Patients Stop Smoking

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.