Quitting smoking can be harder than getting off of heroin. Many factors go into this, including legal (we can walk down the street smoking a cigarette but not crack cocaine), social (we smoke with our "buddies") and habitual (we are in the habit of lighting up when we get in our car, etc.). So it may not be surprising that despite monumental efforts to help people quit, smoking rates haven't declined that much in the last several decades.
E-cigarettes made a big splash recently, with celebrities smoking them on talk shows and companies ramping up their production to rake in profits before the FDA comes in and regulates them (see this recent Time magazine article). The tag line is that it is better to use an e-cigarette than smoke the real thing. But do they really help people quit?
In a recent study published in the Lancet, one of the U.K.'s top medical journals, Bullen and colleagues compared individuals who received 13 weeks of 1) e-cigarettes loaded with nicotine to 2) e-cigarettes without nicotine (placebo condition) to 3) nicotine patches. They measured quit rates six months later (the gold standard for smoking cessation trials) and found that the e-cigarettes were no better than the patch, or even the placebo condition (rates for all three ranged from 4-7 percent) and concluded, "uncertainty exists about the place of e-cigarettes in tobacco control..." Another curious fact was that fully one-third of individuals who received e-cigarettes reported continuing to use them at six months, suggesting that they may become long-term users (which is certainly good news for the e-cigarette manufacturers!).
So if e-cigarettes can't cut it, what's next?
A few colleagues and I were recently invited down to the White House by the Office of National Drug Control Policy (ONDCP) and Substance Abuse and Mental Health Services Administration (SAMHSA) to present at a technology innovations conference. The idea behind this was to get a sense of what tech tools are being developed to help individuals with substance use and other mental disorders at their point of contact -- not when they are sitting in their doctor's office or talking to their therapist, but when they are in their car, craving a cigarette after a big fight with their spouse or partner. For example, in an elegantly simple first step, Dr. Adam Kaplin from Johns Hopkins presented a program he developed named "Mood 24/7" which allows patients to quickly and easily rate their mood throughout the day via text messaging (all you quantified selfers out there: Go for it!). The nice bit here is that not only can folks follow their mood trends, but their doctors can track these as well, helping them objectively link these data to starting or changing medications -- for example, a great way to see if that increase in Prozac correlated with improved mood.
Dr. David Gustafson from the University of Wisconsin presented a mobile app that that provides resources and support for individuals in addiction recovery when and where they need them. Linked to GPS and other personal data, the app can tell if someone is moving toward a location where they used to score drugs and then can give them escalating alerts to use their recovery resources, including even prompting a call to support staff!
Along the same lines, I presented Craving to Quit, a smartphone app that delivers mindfulness training in bite-sized pieces of 3-10 minutes a day via video and animation. This helps with delivery, as people don't have to come in to our clinic for treatment -- they can do the training whenever and wherever is best for them, and cuts down on costs as well. Similar to Gustafson's approach, it has a built in "want-o-meter" so that anytime someone craves a cigarette, it will walk them through a mindful exercise to ride out their craving in that moment.
At the end of the conference, it was pretty clear that technology is going to make a big impact in helping treat addictions and other mental disorders; it seemed that one of the key unifying features that folks are working on is being able to track and literally help people break their habit loops in their own environment (see my previous blog on why this is so important). This makes a lot of sense, because contextual cues are where the action is -- where habits get laid down and reinforced, and following logically, where they can also be broken.
These technologies will only become better over time, as the features of how best to deliver effective treatment through one's phone (hint: Texting may not quite cut it) is paired with the wizardry that is already out there (GPS etc.). And in 10 years, we will likely look back at things like e-cigarettes and try to remember why we thought they were such cutting edge in the first place.
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1. Bullen, C., et al., Electronic cigarettes for smoking cessation: a randomised controlled trial. The Lancet, 2013(0).
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