A Mindfulness Based Application for Smoking Cessation

Cigarette smoking is the leading cause of preventable death and disability in the world,
accounting for 10% of all deaths. In the US, smoking costs more than $193 billion in health
care costs and lost productivity per year. Although over 70% of smokers want to quit, fewer
than 5% achieve this goal annually. Mainstay behavioral treatments for smoking have focused
on teaching individuals to avoid cues, foster positive affective states, develop lifestyle
changes that reduce stress, divert attention from cravings, substitute other activities for
smoking, learn cognitive strategies that reduce negative mood and develop social support
mechanisms. These have shown modest success, with abstinence rates between only 20-30% over
the past thirty years. This is presumably due to the complex nature of the acquisition and
maintenance of nicotine addiction, including associative learning mechanisms as well as
positive and negative reinforcement. Over time, cues that are judged to be positive or
negative can induce affective states, which can then trigger a craving to smoke. Though the
centrality of craving remains controversial, evidence suggests that craving is strongly
associated with smoking, which, mainly through the physiological properties of nicotine,
results in the maintenance or improvement of positive or reduction of negative affective
states. This sets up reinforcement loops by reinforcing memories between affect and smoking.
Thus, attention has been focused on additional strategies to help people tolerate negative
affect and cravings rather than avoiding cues or substituting activities, and recent
research suggest that MT may decouple the association between craving and smoking, thus
facilitating smoking cessation.

Mindfulness training (MT) targets affective or craving states by teaching individuals to
observe aversive body and mind states instead of reacting to them with habitual reactions,
thus allowing more adaptive, healthier responses. Mindfulness training (MT) has shown
promise in reducing anxiety and depression and has recently been explored in the treatment
of addictions. In a 2011 randomized controlled trial by Brewer, et al., individuals who
received an 8- session MT vs. the American Lung Association's 8 session freedom from smoking
(FFS) treatment, showed significantly greater rate of reduction in cigarette use and greater
point prevalence abstinence rates during treatment and maintained these gains during follow
up. FFS is a behavior modification program and includes stress reduction and relapse
prevention. Although both treatment groups were assigned home practice as part of their
treatment, only those who received mindfulness training demonstrated a significant
association between home practice and smoking outcomes, suggesting that there was a specific
benefit to mindfulness practice and that positive treatment outcomes for those in this group
are not merely a result of greater enthusiasm or interest in quitting. The ability of MT to
attenuate the relationship between craving and substance use has been observed in other
studies as well. Elwafi, et al. (2012) demonstrated that people who practiced mindfulness
more smoked less, regardless of their level of craving. Practicing mindfulness appears
critical to MT treatment outcomes. These results suggest that MT may help individuals
develop a tolerance to craving itself, thus over time acting to dismantle the addictive
loop. To date, research in this area has been conducted in randomized clinical trials in
structured laboratory settings only. Important next steps are to examine the effectiveness
of MT treatments for smoking cessation in naturalistic environments and to utilize methods
of delivering treatment in real world settings that will facilitate compliance with
mindfulness practice and thus improve treatment outcomes - for example, via a mobile device
application. Additionally, trials comparing MT to alternative treatment approaches typically
offered in outpatient clinics such as support groups, acupuncture, individual counseling, or
nicotine replacement therapies are lacking. Mindfulness based (MT) smoking cessation has
been adapted to a mobile device application called "Craving to Quit" based on the work done
by Brewer and will be the mindfulness intervention used in this study. Standardization and
implementation via a mobile application is a logical and necessary next step in the
dissemination of treatment and will potentially provide access to an effective smoking
cessation program for persons who may not otherwise be able to access treatment.

Inclusion Criteria:

- Males and females who have given written informed consent

- 18 years of age or older

- Smoke an average of a minimum of five cigarettes per day

- Literate in English and able to read, understand, and complete the rating scales and
questionnaires accurately, follow instructions, and make use of mindfulness
techniques

- Express a wish to quit smoking

- A score at least in the "contemplation" range, as assessed via the Readiness to
Change questionnaire (Heather & McCambridge, 2013)

- Willingness to participate in mindfulness techniques

- Able to attend all clinic visits without interruption

Exclusion Criteria:

- Any current Axis I DSM-IV-TR psychiatric disorder other than alcohol abuse, marijuana
abuse, or nicotine dependence that, in the clinician's opinion, warrants treatment or
would preclude safe participation in the protocol, including, but not limited to:
psychosis, schizophrenia, dementia, schizotypal personality disorder, borderline
personality disorder, bipolar disorder, primary diagnosis of eating disorder, or
chronic suicidality or homicidality

- Serious medical comorbidity requiring medical intervention or close supervision,
including seizures, pacemakers, heart transplant, severe arrhythmias, or active
atrial fibrillation

- Suicide attempt in the last thirty days

- Gross neurological disease

- Mental retardation, which will be assessed by the PI, postdoctoral fellows, and
doctoral students in clinical psychology

- Minors below the legal smoking age