Cycle of addiction
The cycle of addiction explains why people cannot stop smoking. But it does not explain why smokers who abstained for many years suddenly start again. I had a client today who has got me re-thinking everything I know about smoking.
This client smokes 25 to 30 a day now but was able to give up for a year. He started again about twelve months ago after a breakup with his long term girlfriend. He came to see me because a few weeks ago he broke up with the latest girlfriend as well and had started smoking really heavily.
I suppose the simple answer is to learn to keep his relationships going. That is not likely to happen, but it got me thinking about why this would start him smoking again. It is well known that stressful events trigger smoking in current smokers, and often make ex-smokers start again.
Cycle of learned behavior
The basic psychology of learned behaviour is CUE-RESPONSE-REWARD. The person gets stressed, lights up, and then feels better. That is the cycle. The addiction comes when the cycle changes to CUE-ANTICIPATION OF REWARD-RESPONSE. The smoker gets a stress cue, immediately thinks of the reward, wants the reward, and then lights up to get the reward. If the smoker does not get the reward, that is, if the smoker does not immediately light up, then the lack of expected reward turns into a craving aimed at making the person do the response. If the smoker does not get the response the result is either anger or depression.
Most smoking therapies focus on the CUE: teaching the client how to ignore the cue. Some focus on the RESPONSE: change how the smoker behaves, suggesting other things to do instead. Some focus on the REWARD: changing the effect of smoking into a bad taste instead of the reward.
But the smoking problem is really in two parts: stopping smoking, and not starting it again. The time between these two points can vary from five minutes to five years.
Is stopping smoking actually a two step process?
But this analysis got me thinking. If the smoking is the response to cue, then you have to look at the cues. The cues are well known: time of day, finishing a task, having a break, getting away from a stressful situation, eating, drinking, after sex, and so on. These are the cues for the current smoker. They are not the cues for the past smoker. The ex-smoker goes through all of these without smoking. So what is different that makes an ex-smoker into a start-again-smoker?
My clients tell me that it is almost always some sort of stressful life event. Every smoker gives up before having the next one. Most smokers don't want a next one, so they are in effect forced into it in order to deal with their stress (which may be purely internal). The required level of stress for some people is trivial, and for others it is high. For successful ex-smokers the required level is very high, so high that they don't start again ever. For others there is some level of stress they cannot deal with, some level that will trigger the smoking behaviour again.
If that is the case then would it not be better to teach the client how to deal with life event stress as part of the therapy?