Mindfulness training for smoking cessation: Results from a randomized controlled trial

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Abstract

Background

Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials.

Methods

88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20 cigarettes/day were randomly assigned to receive MT or the American Lung Association's freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17.

Results

88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F = 11.11, p = .001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p = .063), which was significant at the 17-week follow-up (31% vs. 6%, p = .012).

Conclusions

This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Introduction

Cigarette smoking along with other tobacco use is the leading cause of preventable death in the world, associated with approximately five million people annually, and accounting for 10% of all deaths (Jha et al., 2006). In the US, smoking costs more than $193 billion in health care and lost productivity per year (Center for Disease Control, 2007). Although over 70% of smokers want to quit, fewer than 5% achieve this goal annually (Center for Disease Control, 2007).

As outlined in models previously (Baker et al., 2004, Curtin et al., 2006), acquisition as well as maintenance of nicotine dependence is a complex process, developed by associative learning mechanisms and perpetuated through positive and negative reinforcement. Habitual smoking begins in part from the formation of associative memories between smoking and both positive (e.g., after a good meal), and negative (e.g., when “stressed”) affective states (Bevins and Palmatier, 2004, Brown et al., 1996, Kandel and Davies, 1986, Leknes and Tracey, 2008, Piasecki et al., 1997). Subsequently, cues that are judged to be positive or negative can induce positive or negative affective states, which can then trigger craving to smoke (Baker et al., 2004, Brandon, 1994, Carter and Tiffany, 1999, Cox et al., 2001, Hall et al., 1993, Huston-Lyons and Kornetsky, 1992, Kassel et al., 2003, Perkins et al., 2010, Shiffman and Waters, 2004, Strong et al., 2009, Zinser et al., 1992). Though the centrality of craving remains controversial (Perkins, 2009, Tiffany, 1990, Tiffany and Carter, 1998, Tiffany and Conklin, 2000), evidence suggests that craving is strongly associated with smoking, which, mainly through the psychophysical properties of nicotine (Imperato et al., 1986), results in the maintenance or improvement of positive, or reduction of negative affective states (Cook et al., 2004, Perkins et al., 2010, Shiffman et al., 1997, Zinser et al., 1992). This sets up positive or negative reinforcement loops, respectively, by reinforcing associative memories between these affective states and smoking (Baker et al., 2004, Bevins and Palmatier, 2004, Brandon and Baker, 1991, Carmody et al., 2007, Carter et al., 2008, Carter and Tiffany, 2001, Cook et al., 2004, Hall et al., 1993, Hyman, 2007, Rose and Levin, 1991, Warburton and Mancuso, 1998).

Mainstay behavioral treatments for smoking have focused on teaching individuals to avoid cues, foster positive affective states, develop lifestyle changes that reduce stress (e.g., practice relaxation), divert attention from cravings, substitute other activities for smoking, learn cognitive strategies that reduce negative mood, and develop social support mechanisms (Fiore et al., 2000, Fiore et al., 2008, Lando et al., 1990). These have shown modest success, with abstinence rates hovering between 20 and 30% over the past three decades (Law and Tang, 1995, Shiffman, 1993). This may be because triggers are often ubiquitous, and diversion of attention requires cognitive reserves, which are often depleted after strong negative affective states (Muraven and Baumeister, 2000). Also, substitutions (e.g., eating candy or carrot sticks) are not always available. The evidence for affective states and craving as perpetuators of smoking, coupled with the modest success of current treatments, highlights the need for innovative treatments (Niaura and Abrams, 2002).

Thus, recently developed smoking cessation treatments have begun to target components of the addictive process by helping patients tolerate negative affect and craving rather than avoiding cues or substituting other activities (e.g., “urge surfing” techniques in cognitive behavioral therapies) (Carroll, 2005, Marlatt and Donovan, 2005). Recent work has focused on recognition and tolerance of negative affect states. For example, in an uncontrolled trial, 16 participants who underwent distress tolerance training (six individual + nine group sessions + 8 weeks of nicotine patch), 1-week point prevalence abstinence was 31% at the end of treatment, but 0% at the 26-week follow-up (Brown et al., 2008). Acceptance and commitment therapy (ACT), which includes an emphasis on tolerance and “defusion” of aversive states has also has shown preliminary efficacy for smoking cessation (Gifford et al., 2004, Hernandez-Lopez et al., 2009). Gifford and colleagues randomized 76 participants to nicotine replacement or ACT (seven individual + seven group sessions), and found 33% and 35%, respectively, achieved 24-h smoking abstinence in NRT and ACT after treatment, 11% and 23%, after 6 months, and 15% and 35% 1 year later (Gifford et al., 2004). Though preliminary, these studies suggest that targeting affective states may aid smoking cessation.

Thus, treatments that target both affective states and craving, such as mindfulness training (MT), may be helpful in smoking cessation (Brewer et al., 2009). Mindfulness approaches have been operationalized to include two components: (1) maintaining attention on the individual's immediate experience and (2) maintaining an attitude of acceptance toward this experience (Bishop et al., 2004). Through these complementary components, MT has been hypothesized to not only bring habituated behaviors into consciousness such that they can be worked with effectively, but also target the associative learning process with an emphasis on affect and craving as critical components of positive and negative reinforcement loops (Brewer et al., 2010b). For example, similar to treatments such as ACT that place an emphasis on accepting one's immediate experience, MT may help individuals learn “sit with” negative affect, cravings, and nicotine withdrawal without habitually reacting to these unpleasant states by smoking. Further, and perhaps somewhat unique to this practice, MT emphasizes the ability to perceive the selfless quality of affective/mind states in that it teaches individuals to recognize these as transient feelings and sensations in the mind and body rather than something that is happening to ‘them’. In doing so, individuals may learn to (literally) not take affective and withdrawal states personally, which also may help them quit smoking (Brewer et al., 2010a, Teasdale et al., 2002). Thus, MT may have the relative advantage of teaching a single technique that may lead to the dampening and eventual dismantling of the complex interrelated associative processes of smoking rather than just removing stimuli that might propagate them.

Treatments that include MT have shown promise for a number of disorders, including anxiety and depression (Hofmann et al., 2010) and have recently been explored in the treatment of addictions (Bowen et al., 2009, Brewer et al., 2009, Zgierska et al., 2008). Data on the efficacy of these approaches remain rare: a recent review reported that of 22 published studies that included mindfulness, only one was a randomized control trial (as an add-on treatment) (Zgierska et al., 2009). Mindfulness approaches have only recently been extended to smoking (Bowen and Marlatt, 2009, Davis et al., 2007). For example, in an uncontrolled pilot study for smoking cessation, Davis and colleagues provided 8 weeks of mindfulness-based stress reduction and found 10 of 18 smokers were abstinent at a 6 week post-quit follow-up visit (Davis et al., 2007). These encouraging findings provide a basis for larger, controlled trials of MT for smoking cessation.

Though MT has been incorporated into other treatments, such as cognitive therapy (mindfulness-based cognitive therapy; Segal et al., 2002) and relapse prevention (mindfulness-based relapse prevention; Bowen et al., 2009, Brewer et al., 2009), as well as ACT, to our knowledge, its efficacy as a stand-alone treatment (i.e., not as a component of or combined with another form of treatment) for smoking cessation has not been compared to empirically based smoking cessation treatments.

In this report, we describe outcomes from a preliminary trial in which we evaluated the efficacy of MT compared to the American Lung Association's freedom from smoking (FFS), a manualized, validated, widely disseminated treatment for smoking cessation (Addington et al., 1998, American Lung Association, 2010, Lando et al., 1990). The primary objective was to assess the efficacy of MT vs. FFS using 1-week point prevalence abstinence and number of cigarettes smoked/day as primary endpoints at treatment completion and a 17-week follow-up. As we have previously found positive relationships between homework completion and substance use outcomes with behavioral treatments (Carroll et al., 2005), our secondary objective was to assess correlations between the amount of completed home practice in both treatment arms and smoking outcomes. We hypothesized that MT would demonstrate at least similar efficacy as FFS with regards to smoking cessation and would show greater correlations between amount of home practice and these outcomes.

Section snippets

Study design

This study was a randomized, controlled pilot trial with a 4-week treatment and post-treatment follow-up interviews at 6, 12 and 17 weeks after treatment initiation. It was approved by the Yale University and Veteran's Administration institutional review boards.

Study population

Participants were recruited through flyers and media advertisements offering behavioral treatment for smoking cessation. Those eligible were 18–60 years of age, smoked 10+ cigarettes/day, had fewer than 3 months of abstinence in the past

Participants

Baseline and demographic characteristics were comparable between treatment groups (see Table 1). Overall, 45% of participants were members of ethnic minority groups, and 63% were men. On average, participants were 46 years old, smoked 20 cigarettes/day, started smoking regularly at the age of 16, and had 5.2 previous quit attempts. Sixteen (eight in each group) did not complete baseline paperwork and were not exposed to treatment. χ2 and ANOVA analyses revealed no differences between these

Discussion

This, to our knowledge, is the first randomized clinical trial to evaluate the efficacy of mindfulness training as a stand-alone treatment for smoking cessation compared to an active, empirically supported control condition. Despite comparable treatment retention and completion rates, we found that individuals who received MT demonstrated greater reductions in smoking, which were maintained through the 17-week follow-up interview. These findings are encouraging as behavioral treatments have

Role of funding source

This study was funded by the following grants: NIDA K12-DA00167, P50-DA09241, K05-DA00457, K05-DA00089, UL 1 DE019586-02, and the U.S. Veterans Affairs New England Mental Illness Research, Education, and Clinical Center (MIRECC). The NIDA and VA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Contributors

Authors Brewer, Carroll and Rounsaville designed the study. Author Brewer wrote the protocol and conducted the study. Authors Brewer, Byrne, Deleone, Johnson, Kober, Mallik, Minnix-Cotton, and Weinstein collected data. Authors Babuscio, Brewer, Mallik and Nich analyzed the data. Authors Babuscio, Brewer, Carroll, Mallik, Nich, and Rounsaville interpreted the data. Author Brewer wrote the manuscript. Authors Babuscio, Carroll, Kober, Mallik, Nich, and Rounsaville edited the manuscript. All

Conflict of interest statement

None.

Acknowledgments

We would first like to thank the participants in this trial. Secondly, we’d like to thank Brian Kiluk and Brent Moore for statistical consultation, Zev Schuman-Olivier for helpful comments on the manuscript, Sarah Bowen and Neha Chawla for help with manual development, Ginny Morgan, Joseph Goldstein, Sharon Salzburg, Pat Coffey and others for help with development of specific elements of the manual, and the staff of the Yale Therapeutic Neuroscience Clinic, and Psychotherapy Development

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