Smoking kills.

The science behind that stone-cold statement has been indisputable for decades. Yet smoking remains the leading cause of preventable death in the United States and around the world.

Given all that we know about smoking, why do people have so much trouble quitting? As an addiction psychiatrist and neuroscientist, it’s a question I frequently get from my patients and acquaintances. The two-part answer I give them is simple: Quitting is hard, and most people go about it the wrong way.

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To explain, let me briefly delve into the science of addiction. The brain has a built-in reward-based learning system. Doing something that makes you feel good provides a reward that reinforces the behavior. Each puff of a cigarette delivers highly addictive nicotine to the bloodstream, and thus to the brain. As nicotine binds to receptors in the brain, it triggers a rush of dopamine, a neurotransmitter that plays a role in motivating behavior. Each time a smoker smokes, it reinforces a brain pathway that says, “This is great, do it again.”

Because reward-based learning is about immediate satisfaction, and nicotine is fast-acting, smokers get stuck in a habit loop that is tough to interrupt. Behavioral economics has shown that even knowledge of the long-term consequences of smoking can’t compete with the immediate positive reinforcement — our brains privilege immediate gratification over future rewards.

Breaking this habit loop is no easy feat. E-cigarettes, partial nicotinic receptor agonists like varenicline, and nicotine replacement therapies such as patches and gum offer a path away from combustible cigarettes, but they still ignore the psychological root of the problem. Given nicotine’s half-life of roughly two hours, nicotine replacement therapies help most with physiological withdrawal, making it possible for smokers to cut down to about 10 cigarettes a day. Below that number, context-dependent triggers drive psychological cravings, which aren’t affected by approaches such as nicotine replacement.

Methods such as chewing gum or using substitutes like carrot sticks focus on surface-level distractions and haven’t been shown to yield lasting results. Using willpower to quit, also known as going cold turkey, works for some people, but most research has shown it to be ineffective, and even counterproductive in some cases, because the willpower part of the brain (the prefrontal cortex) goes offline when stressed, which is a main trigger for smoking.

What’s the solution? Changing the habit loop.

To help my patients quit, I coach them to employ mindfulness techniques designed to break bad habits. This works by hacking the reinforcement process in two ways: It updates the reward value of smoking in the brain, and it helps people ride out their cravings instead of acting on them.

The first step of a mindfulness approach involves becoming aware of the immediate effects of smoking. For example, when I have my patients pay attention to smoking, they describe a “burning feeling” as they inhale, and mention that cigarettes don’t taste good and the smell of smoke is unpleasant. Paying attention to the experience of smoking is quite different than distractedly smoking while staring at a smartphone or talking to someone. Potential quitters then learn techniques to ride out cravings by focusing on associated physical sensations such as tightness, heat, contraction, and the like, and simply being aware of them over time as they come and go (rather than reactively and automatically smoking, distracting oneself, or doing something else to make the sensations go away).

This works by decoupling the link between craving and behavior, effectively dismantling the habit loop instead of treating around it.

Thanks to advances in technology, it’s no longer necessary to make an appointment with someone like me to learn mindfulness techniques. The emerging field of digital therapeutics — online treatment for physical and psychological health — now brings smoking cessation programs to the palm of your hand through smartphone apps. Though not a panacea, some evidence-based mindfulness apps like the one my colleagues and I recently described in the journal Neuropsychopharmacology show promise in targeting specific brain networks associated with getting caught up in craving compared to traditional approaches to smoking cessation.

Of course, quitting wouldn’t be such a gargantuan problem if fewer people started smoking, but that’s an essay for another day.

Jud Brewer, M.D., is the director of research and innovation at the Mindfulness Center at Brown, associate professor in behavioral and social sciences at the Brown University School of Public Health, associate professor of psychiatry at the Warren Alpert Medical School of Brown University, and author of “The Craving Mind: From Cigarettes to Smartphones to Love — Why We Get Hooked and How We Can Break Bad Habits” (Yale University Press, 2017).

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  • I just looked at this interesting piece. Although it may hold promise for Reducing smoking, I think it is important to emphasize the preliminary nature of the findings underlining this article. The randomized trial only has 33 participants. If I am not mistaken, there was no difference between the study group and the controls. Were the findings confined to subgroups? We need many more, and larger RCTs before we recommend treatment.

  • I started smoking when I was 16 and quit when I was 26. When I quit I smoked 2 packs a day. Cigarettes were about to jump in price to 50 cents a pack – no way was I going to smoke up a dollar a day. I knew smoking was unhealthy but the cost got to me. I thought it would help if I bribed my young daughter – “you quit sucking your thumb and I will quit smoking.” Didn’t work. What really did the trick was to tell myself every time I lit up that I didn’t smoke anymore. And one day I wasn’t and never misssed it. No withdrawal cravings. What got me using this technique was reading about athletes that sometimes exercised mentally to good effect.

    • Excellent Pat. Over $500 billion in annual product marketing, the traveling hypnotist, and a heartfelt quitting reasons list all suggest that subconscious messaging somehow works, especially as we doze off, the moment our two minds draw nearest. Could it be that the mind’s crave generators, our insula, dopamine, and fight or flight pathways, can be re-purposed (at least temporarily) to see the natural insecticide nicotine as the enemy?

  • It’s hard to find a cookie containing fewer than 50 calories. We’d need to walk a half-a-mile to burn 50 calories, and a full mile to burn two. It simply isn’t worth it. Sugar and processed foods are not our friends, as the liver easily converts them to fat. Diets are temporary programs that end. Having shed 40 pounds in the past 70 days, I’ve discovered that vegetables, fruits, nuts, and lean meats are my body’s friends.

    Having arrested my 3 pack a day, 30-year smoking dependence twenty years ago, what I discovered is that, like refined foods and sugar, nicotine is the body’s enemy. But there’s one critical difference. While we can get away with a cookie now and then, brain scan studies teach that just one puff and up to 50% of dopamine pathway receptors become occupied by nicotine. While most who cheat when quitting walk away feeling like they’ve gotten away with it, it isn’t long before they find their mind wanting, plotting to obtain or even begging for more. Smoking relapse studies suggest that the distinction between lapse and relapse is unnecessary, that one equals all, that one puff would be too many, while thousands wouldn’t be enough. There’s only one rule that if followed makes failure impossible. No nicotine today, to never take another puff.

  • Calm and peaceful mind states that can be achieved through mindfulness meditation can further facilitate someone to quit smoking (i.e., the agitated mind that always needs external stimulation vs. a calm mind that can find happiness and peace on its own).

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