cease certain marketing practices and to pay states the medical
costs of people who had developed smoking-related illnesses.
“It’s been a collective effort — no one has worked alone,”
says Orleans. “Together we’ve had an extraordinary effect on
the health of the American population, and the health of the
Origins of our knowledge
Psychologists started making their mark in tobacco control
years before the 1964 report, says David Abrams, PhD, of
the Schroeder Institute, Johns Hopkins and Georgetown.
The origins of the basic knowledge of addiction began in the
1940s, he says, when psychologists used classical and operant
conditioning to test behavioral responses in lab animals.
“Nicotine and tobacco have been at the forefront of the
models being used to understand the brain mechanisms that
lead to the reward pathways of addiction,” Abrams says.
By the mid-1970s, he and others were continuing to conduct
tobacco- and nicotine-related basic science, linking animal
models to human research. Through human laboratory studies,
Abrams was able to uncover the basic mechanisms behind
relapse that are triggered by stress and the sights and smells of
other people who are smoking — known as cue reactivity or
stimulus-induced craving, phrases that have become staples in
the addiction-treatment lexicon.
Another psychologist to lay the basic groundwork for
understanding the effects of nicotine was Saul Shiffman, PhD,
now a professor of psychology at the University of Pittsburgh.
In the early 1980s, “many people doubted that smoking was
addictive, and documenting withdrawal and providing a way
to assess it helped turn the tide toward recognizing smoking as
nicotine addiction,” he says. That distinction was made clear
in the1988 surgeon general’s report, which made a point of
substituting the word “addiction” for “habit” throughout.
The work of Shiffman and other psychologists also informed
critical research on treatments that identify situations, thoughts
and behaviors that spur quitting or relapse and pose cognitive-behavioral strategies to help people anticipate or avoid such
triggers. A person may be tempted to smoke under a situation
of work stress, for instance, but learn to substitute positive
coping strategies such as relaxation techniques or reframing
negative thoughts that would normally provoke smoking.
A major psychological model that employs such techniques
is harm reduction, developed and widely disseminated by the
late G. Alan Marlatt, PhD, of the University of Washington. It
includes a component called relapse prevention, or strategies
to cope with the cues and temptations of a given addictive
behavior, in this case, smoking.
The model takes a pragmatic approach to addiction,
acknowledging that some people won’t be able to quit
immediately, fully, or forever. If a person starts to use again after
a period of abstinence, they can learn from the lapse and try
again until they succeed. The model also holds that small steps
toward quitting are OK — that a goal can be controlled use,
rather than complete cessation.
Relapse prevention contrasts with the disease model of
addiction, which holds that addiction is a life-long, biologically
based disease that can only be countered by abstinence,
discipline, outside help and avoidance of triggers. Examples are
Narcotics Anonymous and other Twelve Step programs. While
such programs are effective for many, Marlatt understood they
wouldn’t work for all users, some of whom can’t quit either
temporarily or permanently. Thus, in Marlatt’s view, reducing
harm is a better strategy than an intervention that doesn’t work
Susan Curry, PhD, now dean at the University of Iowa’s
College of Public Health, worked with Marlatt to elaborate on
the relapse prevention approach during a collaboration in the
1980s. A 1987 article they published in the Journal of Clinical
and Consulting Psychology, for instance, demonstrated the
“abstinence violation effect,” which describes people’s tendency
to overreact to minor lapses from attempted abstinence with
guilt, resignation, and sometimes, by relapsing.
Meanwhile, Shiffman was conducting extensive research that
gathered data from people struggling to avoid relapse in order
to identify factors that cause such relapse — rising emotional
distress in the hours preceding a lapse, for instance. The
research, which relied on real-time, real-world data collected by
electronic diaries, also reinforced the importance of cognitive
and behavioral coping in overcoming such obstacles.
Those data have “informed the content of almost all
contemporary behavioral treatments for smoking,” Shiffman
says. Most if not all treatments emphasize the importance of
avoiding stress and of preparing coping responses for dealing
with it when it does arise. Now, he and colleagues are tailoring
that work by programming smartphones to help smokers
overcome hurdles to quitting.
A broader reach
In the early 1980s, psychologists studying cigarette and nicotine
addiction changed tacks, finding that they could have a larger
impact with broad public health interventions than with
individual interventions alone.
Among them was Oregon Research Institute psychologist
Ed Lichtenstein, PhD. In 1980, he was invited to work for a
year with the National Cancer Institute, whose public health
perspective on cancer prevention and reduction — viewing
the disease from a population-level perspective and developing
strategies based on which ones might have the biggest impact
— inspired him to consider a similar approach to smoking
“The logic of it seemed compelling,” he says. “It was clear we
needed to reach larger numbers of people, and I began to see
some ways of doing that.” These included moving interventions