IB Docs (2) Team
Treatments for addiction
Health psychologists do not only study the origin of a health problem and ways to prevent it, but they also try to find ways to treat people who have the problem. Two different treatments for addiction are outlined below: Nicotine replacement and mindfulness. The final treatment that is examined is highly controversial - a program called Alcoholics Anonymous.
Please note that this is not a required part of the IB curriculum. However, when discussing problems, it is not a bad idea to think about potential solutions...
Nicotine Replacement Therapy
There are four main nicotine replacement products on the market: nicotine gum, nicotine patches (aka transdermal patches), nasal spray and nicotine inhalers. Recently there has been research on the role of electronic cigarettes as a form of NRT. The goal of NRT is to first provide the nicotine without the other negative ingredients of cigarettes, such as tar. Then the smoker receives smaller and smaller doses over time until they are no longer dependent on nicotine. It appears to be most helpful for people who smoke over 15 cigarettes a day. It has not been shown to be effective in people who on average smoke fewer than 10 cigarettes per day.
Here is a good video by Dr. Andrew Pipe on the use of NRT.
A meta-analysis by Hughes (2003) found that NRT is effective to help people to stop smoking. It appears that NRT is twice as effective as simply "choosing to quit." However, the success rate overall is still low. According to the American Cancer Society, with no program, the success rate for quitting smoking is between 5 - 7%. With NRT the rate is 23%, but it drops to 15% after only six months as often patients relapse. So, it appears that although the strategy is effective for some, there are clearly factors that may affect whether the treatment is effective.
Another problem with NRT is that it has the same side effects as smoking, although it is not as dangerous as smoking. NRT may lead to headaches, nausea and digestive problems, sleep problems and high levels of cholesterol.
Even US President Barak Obama has struggled to give up smoking and used NRT (gum) in order to kick the habit.
There is a debate about whether e-cigarettes will help to decrease smoking. Evidence strongly suggests that e-cigarettes may be effective in helping smokers quit and preventing relapse, but there have been few published studies to explain why this might be the case. A study by Bullen et al (2013) found that e-cigarettes were about as effective as nicotine patches in helping people in the study quit smoking. The study was made up of 657 smokers who wanted to quit. For six months, 289 of the participants received e-cigarettes, 295 received nicotine patches, and 73 received placebo e-cigarettes, which contained no nicotine. They found that 7.3% of those in the e-cigarette group had successfully quit smoking, compared with 5.8% in the nicotine patch group and 4.1% in the placebo e-cigarette group. The differences in results are not statistically significant, meaning each group had about an equal chance of quitting.
In a study by Brown et al (2014) they found that people who use e-cigarettes are 60% more likely to quit than those that use willpower alone. The study was made up of 5,863 smokers who had attempted to quit smoking without the aid of prescription medication or professional support. 20% of people trying to quit with the aid of e-cigarettes reported having stopped smoking conventional cigarettes at the time of the survey.
One of the problems with studies of smoking cessation is that there is a sampling bias of people who want to quit. Therefore, it is impossible to rule out the role of motivation in successful treatment. In addition, relapse is rather common. If the addiction were only physiological, one has to wonder why someone would start smoking again after having successfully overcome the physical withdrawal from nicotine. This implies that CBT (cognitive behavioural therapy) may be helpful for clients to avoid relapse by developing strategies to avoid restarting their old habit. This type of therapy is often provided in groups.
Mindfulness
Mindfulness - also known as MBSR - has been used as a way to stop smoking. Unlike NRT which looks at addressing the physiological addiction (a problem-focused approach), MBSR looks at using meditation in order to address the cognitive factors that trigger the craving to smoke (a coping focus approach). Mindfulness has been shown to decrease both stress and negative affect, both of which are correlated with smoking.
Davis et al (2007) carried out a study to test the effectiveness of MBSR on smoking cessation. There were 18 participants, all who smoked an average of roughly 20 cigarettes per day for a period of 26 years. The participants were given mindfulness training once a week for eight weeks. The participants attempted to stop smoking in week 7 of the program. In order to test if the participants had in fact stopped smoking, there were both self-report questionnaires and a carbon monoxide breath test administered. In addition, the questionnaires asked about their level of stress. After six weeks, 10 of 18 subjects (56%) showed that they had been smoke free.
Singh et al (2012) carried out a case study on a 31-year-old man named "Paul" who had smoked for 17 years and smoked on average between 15 and 20 cigarettes per day. He had been trying to quit smoking for almost six years. Singh et al taught him three mindfulness techniques:
- Intention. Paul was taught to verbally state his intention to quit smoke. This included statements like "I will not smoke today" and "I will not smoke anymore."
- Mindful observation of thoughts. He was taught that desires were simply "thoughts" and should be "let go." In other words, he was to be aware of his thoughts, but not respond to them.
- Meditation on the soles of his feet. If the desire thoughts were too strong and could not be let go, he was taught to move his attention to the soles of his feet.
Within three months, Paul was no longer smoking, with the number of cigarettes smoked daily decreasing incrementally over the three-month period. Paul is checked every three months to determine whether he has been able to maintain his behaviour. After three years, he is still smoke-free.
Critically thinking about Alcoholics Anonymous
One of the most famous ways to overcome alcoholism is a self-help group called Alcoholics Anonymous.
Alcoholics Anonymous [AA] members meet in groups to help one another stop drinking and then keep sober. The meetings, which are free and open to anyone serious about stopping drinking, may include sharing stories, celebrating members’ sobriety, as well as discussing the 12 steps related to problem drinking. Members are supposed to correct all defects of character and adopt a new way of life. They are to accomplish these difficult goals without professional help. No therapists, psychologists or physicians can attend AA meetings unless they, too, have drinking problems.
Most studies evaluating the efficacy of AA are not definitive; for the most part, they associate the duration of participation with success in quitting drinking but do not show that the program caused that outcome. Some of the problems stem from the nature of AA - for example, the fact that what occurs during AA meetings can vary considerably. Further, about 40 percent of AA members drop out during the first year, raising the possibility that the people who remain may be the ones who are most motivated to improve.
A study called Project Match (Longabaugh and Wirtz, 2003) randomly assigned more than 900 problem drinkers to receive one of three treatments over 12 weeks. One was an Alcoholics Anonymous based treatment. The other treatments were cognitive-behavioral therapy, which teaches skills for coping better with situations that commonly trigger a relapse, and motivational enhancement therapy, which is designed to boost motivation to stop drinking. The results showed a significant increase in the number of alcohol-free days in all three cases – with about 19% of the participants giving up drinking altogether.
The Project Match study is, however, rather controversial. First, it did not have a control group. Therefore, it is not possible to know the extent to which the therapies played a role in the change of behavior. Secondly, there was no significant difference between the three types of therapy. This could mean that there is another factor, such as foot-in-the-door compliance techniques or simply motivation, which were more important than the actual type of therapy.
Moos & Moos (2006) carried out a 16-year study of problem drinkers who had tried to quit on their own or who had sought help from AA, professional therapists or, in some cases, both. Of those who attended at least 27 weeks of AA meetings during the first year, 67 percent were abstinent at the 16-year follow-up, compared with 34 percent of those who did not participate in AA. Of the subjects who got therapy for the same time period, 56 percent were abstinent versus 39 percent of those who did not see a therapist—an indication that seeing a professional is also beneficial.
That all being said, the Cochrane Collaboration (Ferri et al, 2006) conducted a review of studies conducted between 1966 and 2005 on the effects of AA and reached a stunning conclusion: “No experimental studies unequivocally demonstrated the effectiveness of AA” in treating alcoholism.
ATL: Thinking critically
Read the following article on the effectiveness of Alcoholics Anonymous.
What are the three strongest arguments against AA in this article? Why do you think so?
Which argument do you think is the weakest? How do you think you could possibly "prove the author wrong?"
Checking for understanding
1. What are two examples of NRT?
There are currently four commonly used NRT products: inhalers, gum, patches or nasal sprays. There is still a debate about whether e-cigarettes should be considered an NRT.
2. What does Pipe argue are some of the problems of the way that NRT is often administered by physicians?
He argues that often physicians don't give NRT enough time to actually be effective and blame the patient for a "lack of will."
3. What is one limitation of NRT?
One limitation is that it is still an intake of nicotine - so there are possible side effects and health implications to using NRT. In addition, although NRT helps to address the physical addiction that is caused by nicotine, it does not address the triggers that make one want to smoke. This most probably explains the relatively high relapse rate of ex-smokers. Finally, the actual success rate is relatively low - only 23%. And even in those cases, it is not clear the extent to which motivation plays a role in one's success in kicking the habit.
4. What does current research appear to show about e-cigarettes as a way of quitting smoking?
Most importantly, research on e-cigarettes is very new and there is not yet much support for any position. But so far it appears that e-cigarettes are a better strategy than just willpower. There appears to be no significant difference between e-cigarettes and other forms of NRT.
5. What are the limitations of the two studies on mindfulness and its effect on smoking?
The greatest limitation is the sample size. Singh's study is on a single person and Davis's study is only 18 participants. In Davis's study, there were also some participants who dropped out of the study. Singh's study has the advantage that it is more longitudinal than Davis's study. Another limitation is that there was no control group in either study. Finally, with any study that takes place over 8 weeks where the treatment is only given once per week, it is difficult to know to what extent the participants actually used the MSBR strategies that they were being taught. Although they all reported that they had followed the MSBR training that they had received, it is not possible to actually verify this except through the self-reported data.
6. What is the difference between a problem-focused and a coping focused approach to treating substance abuse and/or addiction?
A problem-focused approach deals with the root of the addiction. In the case of smoking, it would be with the physical addiction to nicotine. A coping focused approach deals with the cognitions that trigger smoking. Many psychologists argue that the best approach to the treatment of addiction in order to avoid relapse is to have a combination of the two approaches.
7. What are some of the difficulties of studying the effectiveness of treatments for substance abuse and/or addiction?
There are several difficulties in carrying out research on the effectiveness of treatments. First, when comparing data often there are differences among the quality of the addiction among the participants. This is why it is important to have large sample sizes in order to reduce the effect of participant variability. It is also important that studies have a control group and that participants are randomly allocated to conditions - ideally with a double-blind design. As many of the studies are done over a period of many weeks, there is always the problem that other variables that cannot be controlled may affect the success of the treatment. Also, there is no guarantee that participants are following the treatment or that they are doing so in line with the recommendations. There is also the problem of participant attrition - that is, often participants drop out of the study. Finally, many of the large studies are done over a shorter period of time, meaning that we cannot know the percentage that would actually relapse in the future. Studies that take a longitudinal approach are expensive and difficult to sustain.
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