Tobacco Addiction Treatment Therapies

One of the main causes of early death, tobacco use is attributed to 5 million deaths every year worldwide (Hatsukami et al, 2008). In comparison to the life expectancy of nonsmokers, around 20 to 25 years are lost to tobacco-related deaths among adults aged 35 to 69 years old. Adults who give up smoking before middle age nearly entirely avoid all of the additional risks associated with smoking (Jha et al, 2006).

Most smokers smoke frequently because they are nicotine addicted. Even in the face of adverse health consequences, compulsive nicotine seeking and abuse characterize the addiction. It is well known that the majority of smokers see tobacco use negatively and indicate a wish to cut back or stop using it. In the US, approximately 35 million smokers annually declare that they want to quit. However, more than 85% of people who attempt to quit on their own, relapse usually within a week (Volkow, 2009).

Although some smokers can quit on their own, many of them require support to do so.

Professional smoking cessation treatments can take many different forms, from basic medical advice to complex withdrawal strategies. Treatment for smoking addiction is mostly based on behavioral group therapies and motivational interviewing techniques, frequently in conjunction with medicinal support (Uehara, 2011).

Besides cognitive-behavioral therapy which is the main approach in tackling addictions in general, long-term approaches such as psychanalytic/psychodynamic and existential approaches which aim to produce permanent change to the individual’s personality could be also used for indirectly treating tobacco addiction.

Cognitive-Behavioral Therapy for Tobacco Addiction

Cognitive-behavioral therapy (CBT) has established itself as one of the most effective psychological interventions for addiction treatment (Hollon and Beck, 2013). It is founded on cognitive and behavioral theories and it is the outcome of combining the study of internal mental processes with behavioral theory in accordance with the scientific paradigm. Cognitive-behavioral therapies present common  essential traits. They are collaborative in nature, structured, short-term, and targeted. Cognitive behavior therapy (CBT) conceptualizes addictions as learned behaviors that could be modified. Addictions are also based on faulty or maladaptive ways of thinking. Treatment with cognitive behavioral therapy generally requires working towards  to altering one's thinking patterns and  modifying the addiction behavior by teaching the client about the conditions and responses that reinforce their  tobacco addiction behavior (Turner et al, 2010).  

 Beck et al. (1993) proposed a cognitive model of any substance misuse where there are three sets of beliefs involved. These are core beliefs (schemata), substance-related beliefs and automatic thoughts. It is therefore important for the CBT counsellor to assist the smoker to understand and challenge their thoughts, beliefs and emotions which cause their tobacco addiction and therefore change their smoking behavior.  Furthermore, identifying conditioned stimuli associated with the smoking is necessary in educating people to stay away from them and become less responsive to them (McAuliffe and Ch'ien 1986). CBT is mostly delivered in groups which  provide guidance in avoiding relapse-triggering acts and create strategies to maintain abstinence from smoking (Matano et al. 1997).

CBT therapy sets particular goals in a particular time frame for the patient (about 14 to 18 sessions). Specific protocols are used and tobacco addiction treatment goals include relapse prevention, developing and applying ways to cope for controlling triggers and maintaining abstinence. (Orchowski and Johnson, 2012).

Motivational interviewing is a widely used approach in smoking cessation which focuses on increasing a tobacco addict΄s motivation,  using four principles as a guide, represented by the acronym RULE: Resist the righting reflex; Understand the patient's own motivations; Listen with empathy; and Empower the patient (Hall et al, 2012).

CBT counsellors act fundamentally as teachers who teach patients how to learn new behaviors and to restructure their cognitions that lead to addictive behavior. They also assist them with  problem solving and goal setting, testing and analyzing affective and behavioral changes related to tobacco addiction. Counsellors are very directive as they are the ones who assess and propose what needs to be changed specifically. (White and Freeman, 2000).

Psychoanalytic-Psychodynamic Therapies for Tobacco Addiction

Psychanalytic and psychodynamic approaches  share a similar terminology for understanding how people function as well as ways for achieving change. Psychanalytic therapy is a strong choice at the addictions treatment field. Early psychanalytic understandings see addictions primarily as trauma reenactments which reoccur in as the addict tries to relive their early life traumatic circumstances in order to integrate or resolve the trauma (Rosenthal and Rugle, 1994).

A main contemporary psychanalytic model of addiction is Khatzian’s (1997) ego deficit model. It is also known as the “self-medication” hypothesis (SMH) in which addicts use substances in order  to alleviate feelings of low self-esteem and self-worth, anxiety and depression.

Wurmser’s (1985)  model views addiction as the result of a harsh superego caused by an early abuse or abandonment trauma. The addict in these cases uses the substance in order to ‘calm’ the superego.

According to attachment theory which is also derived from psychoanalytical concepts, addiction is the outcome of insecure attachment to the mother-figure. The insecurely attached individual  has a tendency towards addictions as he presents a high degree of  emotional deregulation (Flores & Brook, 2011).

Psychanalytic and psychodynamic approaches aim to achieve a long-term personality change that will cause the end of addiction  rather than treating the symptoms or addictive behaviors pe se. The objective of psychoanalytic approaches for tobacco addiction are: a) to provide a caring and supportive relationship as an antidote against the traumatic repetition of the addiction; and b) to assist the smoker to become conscious of the roots of developmental and relational problems that led to tobacco use  by offering an environment where early interpersonal interactions may be relived, understood and changed (Vandermeeren and Hebbrecht, 2012).

Analysis for tobacco addiction is typically long-term and intensive, requiring clients to work through internal conflicts in order to comprehend the unconscious mechanisms that influence their smoking behavior (Barber et al, 2013). Whether in a group or on individual analysis, by engaging with the therapist and/οr other group members the patient can recreate the ways they relate with others in their everyday life and  experience the same feelings (that were created during their early childhood) toward family members. The transference towards the therapist could reveal different unconscious defense mechanisms and resistances which were formed during early childhood and led to the tobacco addiction. In this process the analyst needs to be conscious of their own counter-transference in order to protect the process from their own influence.

The therapist’s role in psychanalytic / psychodynamic therapy can be thought of as being on a spectrum, ranging from detached to more collaborative with the patients (Corey, 2016).  Analysts usually would provide patients  with interpretations at an individual or a group level (Brabender et al, 2004).

Existential Therapy for Tobacco Addiction

Existentialism arose in response to logical positivism's idea that absolute knowledge is possible. (Brabenter et al, 2004).  Existential therapy focuses on the conditions that all humans have to face in life  and the necessity to find meaning and purpose as a way of surviving and doing well in life (Wong, 2017). Different sources of struggle are examined and confronted as unavoidable to common human condition such as death, meaninglessness, isolation and suffering. Clients are seen as having the capacity for freedom and choice and functioning better when they take responsibility of their own life.

People are not seen as individuals, but rather as being in relationship with the world. According to Heidegger's (2010) concept of being-in-the-world (Dasein), existence is fundamentally transcendent, always in relationship with the world.

Existential issues such as alienation , death, meaninglessness etc. seem to be present in the life of people suffering from addictions (Boyd & Mackey, 2000). The inventor of Logotherapy ( the third Viennese School of psychotherapy) and holocaust survivor Viktor Frankl (1969) sees addictions as the consequence of existential vacuum. Addiction could also be explained as a coping strategy for pain and traumatic situation and people. 

The goal of existential psychotherapy is not to cure the tobacco addiction, but rather to create an environment in which individuals can approach and achieve meaning from the 'painful' realities of life that are ignored, avoided, or denied on both the personal and social levels (Yalom, 1995).

Existential therapy sets the conditions for clients to experience the here-and-now, connect with therapist, discover meaning, understand their freedom and take responsibility in their decisions and behaviors (Corey, 2016). When clients choose the path of addiction, they are prone to withdrawing from the world and a limited existence that leads to meaninglessness. To recover entails becoming conscious of the self-transcending component of existence, as well as taking action and living in the world (Kemp, 2011).

The major task of the existential therapist is to be fully and authentically present to the client, as well as to understand their subjective lived experience of addiction. This comprehension of their lifeworld is acquired by person-to-person interaction, self-disclosure, and compassionately challenging clients. This indicates that the therapist takes an active role in tackling the same universal challenges that clients face and clients are encouraged to express their feelings and developing their own unique meanings (Mullan, 1992).

Personal Evaluation and Reflection

CBT is the approach that dominates clinical guidelines for addictions due to its empirical basis and various political reasons. It seems that the fact that it is short-term, goal orientated , cost effective and targeting the smoking behavior makes it the main modality to tackle addictions but nevertheless without any guarantee for success as tobacco addiction like all chronic addictions frequently presents relapses. That is a proof of the complexity of tobacco addiction and that makes me skeptical about whether any short-term (quick fix) approach could really benefit people with addictions in general.

Personally, one of the most appealing aspects of the psychanalytical understandings of tobacco addiction is the fact that they provide very close to my personal experience explanations of tobacco use. For example  Khatzian’s (1997) self-medication hypothesis that sees substances as a way to alleviate emotional pain makes a lot of sense not only rationally but also empirically from my own experience with smoking and several other self-destructive behaviors. Another concept which seems intuitively right,  is the conceptualization of addiction as a slow death or self-destruction which is the ultimate and unavoidable effect of a prevailing death drive (Thanatos) (Kernberg, 2009). The latter explains adequately for me why smokers present a lot of resistance to quit as it seems that the self-destruction is rooted very deeply (perhaps even in their first days in life) and one could perhaps assume easily an association with some sort of an early life trauma perhaps parental neglect, abuse etc.

In more psychodynamic terms, I would see tobacco  as a transitional object,  as a substitute of a real person and a real relationship (Winnicott, 2016). The substance becomes the Other, something that provides safety, alleviation of pain, stress and anxiety, something which is the only way the patient knows to relate with the world in the absence of early healthy relationships primarily with their parents. The object therefore becomes the Other and it is the duty of the therapist to be available  and slowly and progressively be that different Other who would be the first healthy relationship in their life. A healthy relationship with boundaries in which space would be provided in order for the Ego of the patient to develop ( the Ego deficit hypothesis is relevant here). In that context, the therapist needs to acknowledge that the patient expects of him in some way to traumatize him and in fact will even provoke the therapist to act as a person that traumatizes them in order to repeat the trauma and have an excuse for continuing their addiction. Under those circumstances the therapist needs first of all not to fall in the trap of re-traumatizing the patient by either neglecting them or in some way abusing them and at the same time needs to be as Winnicott, D. W. (2016) would say a  ‘good enough mother’,  not over-gratifying their needs but also being present and empathic, focusing on the patient’s real needs  but at the same time not forgetting about their own needs and protect their personal boundaries.

Another way to understand this, would be in terms of attachment theory where the therapist would need to be the first ‘object’ that the patient would need to be securely attached with. It is only with the development of a secure attachment with another person that the insecure attachment with the substance could be disrupted. The more the patient develops healthy emotional connections with others -and the consulting room is the laboratory where this could be learned and achieved- the easier it becomes for them to achieve smoking cessation.

Nevertheless, psychanalytic type of therapy would by default need a lot of time, money and perhaps results would not be guaranteed. Emphasizing on the past does not immediately guarantee  solving the problems that are there in the present and which significantly harm the patient and that is why most addiction programs do not follow a psychoanalytic approach. When going back to the past and becoming insightful of a traumatic experience there is always the risk and danger that the patient may relapse.

Relationship is also a fundamental aspect of existential therapy for addictions. As I see the common humanness between myself and tobacco addicts and how I have not been able for about 20 years to quit smoking, I connect with the idea that we are all temporarily thrown in this world of absurdity and we have to struggle with isolation, meaninglessness in what we are doing with our life. Within that context, we are all faced with the task of becoming something in our life or creating a meaning that would help us not only sustain the overwhelming difficulties that life presents (trauma , pain , loss) but also make life worth living.

It is therefore very appealing to me as a therapist to have the role of a fellow traveler to the patient and helping the person become more autonomous and create their own personal meaning in life. Again similarly with the psychanalytic approach, the existential approach might require a very long time and could cost a lot and without any guaranteed results as the patient might freely decide that the addiction would be still their selected way of being in a world. Even though it does not seem very practical, I strongly believe that existential therapy in the long term could deliver better results.

A crucial factor in selecting an appropriate approach would be the severity of the smoking addiction and the particular goal of therapy. More severe cases with patients who are at the beginning of their recovery journey towards smoking cessation usually after serious health problems like cardiovascular-diseases , would perhaps benefit from cognitive-behavioral  structured and goal orientated interventions with the goal being to immediately withdraw tobacco use. In cases where the goal is long-term , permanent abstinence from tobacco and there is also comorbidity with other disorders, approaches like psychoanalytic or existential would be very beneficial for the clients in order to produce deeper change in their personality structure. When it comes to comorbidity with depression or a personality disorder, I think that all approaches would be equally helpful. Comorbidity with other psychiatric disorders also needs to be taken into consideration when selecting an approach for smoking cessation. In those cases,  CBT interventions are the only way as existential and psychanalytic approaches would require the ability for the patient to express themselves at a required standard (Litt et al., 1992)..

In addition, I would be very skeptical of any individual form of therapy as I think that group therapy of any approach would be much more beneficial and appropriate as the patient in a group has a supporting environment and motivation from their peers which also helps to avoid isolation , stick to their purpose and avoid social environments that might destabilize their efforts. There of course, the job of the therapist is extremely more challenging as they would need to have also strong leadership skills, act as models for the patients, be creative and able to facilitate the group process effectively.  It seems that within the context of a community, change seems to be more possible. 

To sum up, therapy is only one part of tobacco addiction treatment strategy with the other being pharmacology. Although I am mostly positively orientated towards the psychodynamic and existential approaches what I think that should be taken mostly into account in the field of tobacco addiction is what the tobacco addict brings to the table. Any approach is appropriate if it fits the needs, preferences and beliefs of the patient and instead of prioritizing any therapy model the therapist needs to ensure that he is present and available to create a therapeutic relationship with the patient. The therapist also needs to be an expert on the particular substance addiction (tobacco), be creative, be a model for their clients or the group of clients and lead by example in the collaborating process of change.

Conclusion

Tobacco addiction is associated with a high number of deaths around the world and giving up this habit at an early age significantly helps to avoid the risk of diseases leading to an early death. As nicotine addicts can find it hard to quit on their own, different smoking cessation treatments mostly based on CBT and pharmacology are used but addictions are also treated via other longer term approaches like psychanalytic and existential.

The three mentioned approaches focus on different aspects and apply different theories of change regarding tobacco addiction. The selection of the treatment is not only a matter of the effectiveness of the approach or the competence of the therapist for smoking cessation, but most importantly one has to take into consideration the needs of the tobacco addict, the particularities of their case, their beliefs, and the individual requirements. The experience has shown that group settings work better for tobacco addicts. Instead of adhering strictly to a specific approach, tobacco addiction needs to be tackled in a strategic, creative, contextualized way based on the uniqueness of each client’s case.