Smoking Cessation: What’s Next?

November 20, 2013
Judson A. Brewer, MD, PhD

Volume 31, Issue 1

Smoking is the leading cause of preventable morbidity and mortality in the US. The majority of smokers want to quit, but only a fraction achieve this annually. New evidence shows it is possible to teach patients to weaken the link between craving and smoking until they are able to ride out any craving–and consequently quit.

Smoking is the leading cause of preventable morbidity and mortality in the US. The majority of smokers want to quit, but only a fraction (5%) achieve this annually.1 In the past decade, we have seen only one new anti-smoking medication come to market (varenicline; Chantix), and a recent trial of electronic cigarettes (also known as “e-cigarettes”), showed that quit rates were not statistically different between e-cigarettes that contained nicotine and those that did not (placebo) (7% and 4%, respectively).2 Clearly, more work is needed on the pharmacological front to help people quit smoking.

Current guidelines recommend combining pharmacological with behavioral treatment to maximize the likelihood of success.3(pp101-103) Both the American Cancer Society and the American Lung Association developed behavioral treatments a number of years ago that are still offered around the country (eg, Freshstart® Smoking Cessation Program [PDF] and Freedom From Smoking®).

Recently, a new wave of behavioral treatment modalities have popped up, rooted in the idea that if someone is able to be mindful of and accept or allow their cravings to arise without getting sucked into them, they may be less likely to smoke. Several recent studies have shown promise.4 For example, a study of Acceptance and Commitment Therapy, delivered over 7 weeks in 90-minute sessions, found a 30% quit rate compared with 13% with cognitive-behavioral therapy.5 A more recent study of mindfulness training, delivered twice weekly over 4 weeks, found a 36% quit rate compared with 15% with the American Lung Association’s Freedom From Smoking.6[[{"type":"media","view_mode":"media_crop","fid":"21096","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_3510257002372","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1398","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":" ","typeof":"foaf:Image"}}]]

These quit rates are encouraging, but how does just being mindful or accepting one’s urges to smoke actually help patients quit? There is now quite a bit of evidence on how positive and negative reinforcement loops foster smoking.7 From a practical perspective, it may seem obvious that if we smoke when we are stressed out, this sets up the operant conditioning loop to smoke again (or more) the next time we are stressed out, because it gives temporary relief from the stress. And from a scientific standpoint, these loops have been worked out for over a century-in 1898, Thorndike8 described the process; in 2000, Eric Kandel received the Nobel Prize for his work in the sea slug, showing how these are the basis for learning.

In a similar vein, the underpinnings of mindfulness have been known for 2500 years. Buddhism is famous for its simplistic teachings on what are described as the 4 noble truths:

1. There is suffering.
2. Suffering is caused by craving.
3. Letting go of craving ends suffering.
4. There is a path that leads to the cessation of suffering. [Their guidebook on how to do this]

And recently, the science is starting to show that there are more similarities than differences between the mechanisms of mindfulness and operant conditioning.9 For example, in a secondary analysis of the study of mindfulness training for smoking cessation noted above, Elwafi and colleagues10 found that mindfulness practice moderated the relationship between craving and smoking. At baseline, craving and smoking were tightly correlated, whereas after the 4-week intervention, this relationship was absent. In other words, the more individuals practiced mindfulness, the more decoupled craving and smoking became, in effect breaking the operant conditioning loop. These data are promising, because they provide a mechanism for how mindfulness might be working to help individuals quit and stay quit.

From a clinical standpoint, patients are taught to recognize what cravings feel like in their bodies-ie, tightness, heat, burning, restlessness, etc. Because these sensations are generally unpleasant, their habitual reaction is to make them go away by smoking. Here instead, they are taught to simply notice these sensations and investigate what they feel like from moment to moment. The more they can get curious about these sensations, the more they can ride them out as they build and then subside. Each time they do this without smoking, they weaken the link between craving and smoking, until they are able to ride out any craving-and consequently quit smoking.

The next steps for treatments such as these are to disseminate them on a larger scale in a cost-effective manner. Acceptance and Commitment Therapy has shown preliminary success with an Internet-based delivery format,11 and an app-based platform of the mindfulness training described above (“Craving to Quit”) is beginning trials now.


Dr Brewer is the Medical Director of the Yale Therapeutic Neuroscience Clinic and  Assistant Professor of the Yale University School of Medicine, New Haven, Conn. He reports no conflicts of interest concerning the subject matter of this article. For his full bio, please click here.


1. Centers for Disease Control and Prevention. Smoking & Tobacco Use: Fast Facts. Accessed November 19, 2013.
2. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013;382:1629-1637.
3. Fiore MC, Jaén CR, Baker TB, et al. Clinical Practice Guideline. Treating Tobacco Use and Dependence: 2008 Update. Rockville, MD: US Department of Health and Human Services. Public Health Service. May 2008. [PDF:]
4. Carim-Todd L, Mitchell SH, Oken BS. Mind–body practices: an alternative, drug-free treatment for smoking cessation? A systematic review of the literature. Drug Alcohol Depend. 2013;132:399-410.
5. Hernández-López M, Luciano MC, Bricker JB, et al. Acceptance and commitment therapy for smoking cessation: a preliminary study of its effectiveness in comparison with cognitive behavioral therapy. Psychol Addict Behav. 2009;23:723-730.
6. Brewer JA, Mallik S, Babuscio TA, et al. Mindfulness training for smoking cessation: results from a randomized controlled trial. Drug Alcohol Depend. 2011;119:72-80.
7. Baker TB, Piper ME, McCarthy DE, et al. Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychol Rev. 2004;111:33-51.
8. Thorndike EL. Animal intelligence: an experimental study of the associative processes in animals. Psychol Monogr. 1898;2(4):1-8.
9. Brewer JA, Elwafi HM, Davis JH. Craving to quit: psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions. Psychol Addict Behav. 2013;27:366-379.
10. Elwafi HM, Witkiewitz K, Mallik S, et al. Mindfulness training for smoking cessation: moderation of the relationship between craving and cigarette use. Drug Alcohol Depend. 2013;130:222-229.
11. Bricker J, Wyszynski C, Comstock B, Heffner JL. Pilot randomized controlled trial of web-based acceptance and commitment therapy for smoking cessation. Nicotine Tob Res. 2013;15:1756-1764.