Smokers who are prompted to quit by health professionals are encouraged, and more likely, to quit gradually than abruptly. According to new research, however, the widespread use of the cutting down approach may be undercutting the overall potential effectiveness of professional advice (1). Preparing to quit is important, but needs to lead to a successful not endless quit day.
This new research tallies with a 2013 Gallup poll finding that the largest number of successful quitters -- 48 percent -- endorsed "cold turkey" as the most effective method, while only 2 percent endorsed "cut down, then quit" as most effective. Earlier research found smokers using abrupt cessation versus gradual reduction of smoking "were almost twice as likely to abstain for a month or more in their attempt." The authors of that study wonder if "something about cutting down sabotages the attempt."
Why would cutting down gradually on smoking "sabotage," those who want to quit? One possible way is that it increases the reward value of each remaining cigarette. The smoker learns to wait for it like a present on Christmas morning. This is sometimes called the "slot machine syndrome" because the payoff is uncertain and irregular, and it makes the behavior hard to extinguish. As long as you sometimes get what you want, in this case, occasional smoking, you will continue waiting for that outcome: the next cigarette. By contrast, if you are never going to win the game, as in the cold turkey approach, you are more likely to walk away for good.
Being addicted to cigarettes means not being able to take or leave them without stress, tension or strain. That is what makes addiction different from recreational use. Stalling, delaying, or reducing smoking are tactics to avoid smoking, but are also ways to avoid quitting. Once addiction to the nicotine in tobacco sneaks up on them, smokers often struggle to control what has become uncontrollable. Gaining control of their addiction, and trying to prove they are stronger than the cigarette, instead of a slave to it, can become a matter of personal pride. The need to quit not control smoking, in this scenario, and in the upside down world of addiction, can become an admission of weakness, and paradoxically be seen as a personal failure.
When it comes to the moment of truth of quitting, the crucial question becomes: Is the smoker saying goodbye to cigarettes by admitting that the addiction has gotten the best of them, that the relationship has gone bad and they need to quit it completely? Or is the smoker, instead, waiting to smoke again and holding out for the next puff?
Suggesting to smokers, who often struggle with vague fears of quitting, that they gradually reduce smoking reinforces the widely prevalent ideas that they just have to want to quit, or try harder, or have more self-control to quit. These often unrealistic notions risk increasing smoker's frustration, isolation and despair. They risk undermining, rather than building, the confidence to make a clean break and to quit as intended.
Smoking is more than a physical problem requiring more willpower. Today's smokers need to better understand the emotional relationship they have to the cigarette. Do they want to be married to it, and smoke all the time, separate from it but still "date" by gradually reducing their involvement, or get a divorce, quit altogether, and move on with their lives?
Dr. Daniel Seidman is director of smoking cessation services at Columbia University Medical Center, author of the book Smoke-Free in 30 Days, and of the Up in Smoke program from Mental Workout for iPhone, Android, Mac, and PC.
1. Michael Ussher, Jamie Brown, Abirami Rajamanoharan, & Robert West. How Do Prompts for Attempts to Quit Smoking Relate to Method of Quitting and Quit Success? ann. behav. med. (2014) 47:358-368.
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