Why does a lapse in smoking cessation so often lead to a relapse?

A friend of mine was a heavy smoker for many years. He had attempted to quit on several occasions; actually did quit several times, only to eventually resume smoking. Each relapse began with the smoking of a single cigarette. That cigarette would invariably be followed by another, and another, until something resembling his previous smoking pattern had become reestablished.

My friend’s experience is not unusual. Research indicates that as many as 9 out of 10 smokers who attempt to quit, resume regular smoking within one year. Each relapse, of course, begins with the smoking of a one or more cigarettes in what might be considered a lapse, or a slip. The vast majority of individuals experiencing such a lapse subsequently resumes a regular pattern of smoking.

Researchers have reported that from 79% to 97% of those experiencing a smoking lapse subsequently continue smoking. Why is it that so many of those attempting to quit resume smoking following a lapse? Why do so few overcome what could conceivably be a temporary setback? Does a lapse itself directly cause a relapse, or does it set in motion other factors that increase the probability of a relapse? A study published this month in the Journal of Abnormal Psychology published by the American Psychological Association casts light upon these issues.

Various theories have suggested a number of different mechanisms that may operate when a smoker attempting to quit experiences a lapse. A “pharmacological” explanation proposes that a lapse exposes the person to the effects of an addictive substance, in this case, nicotine, which reinstates a strong craving, thus motivating attempts to acquire more of the drug.

There is also believed to be an effect produced by “nonpharmacological” factors. It has been shown in animal studies that cues associated with a drug that are presented during a lapse can increase the animal’s motivation to reacquire the drug. The appearance of the cigarette itself, the feel of the cigarette between the fingers or the lips, the ritual of lighting up, and the taste and odor of smoke are examples of some of the stimuli associated with smoking.

A third explanation involves so-called “cognitive and affective” reactions, thoughts and emotions which occur as a result of a lapse. According to this idea, a person who experiences a lapse responds with negative thoughts and feelings that undermine his success at quitting. For example, a person who lapses might prematurely conclude that he has failed to kick the habit. He might further label himself a failure, experience feelings of guilt, and depression. These thoughts and feelings promote a resumption of smoking.

Psychologist Laura Juliano of American University and her colleagues at Johns Hopkins conducted a study to in an attempt to illuminate the role of a lapse in promoting a smoking relapse. Smokers were recruited to take part in a “practice quit attempt,” rather than a stop-smoking program. All participants were instructed to quit smoking for 4 days. The subjects were randomly assigned to one of three groups. Following the 4 days of abstinence from smoking those in two of the groups were instructed to lapse by smoking five cigarettes provided by the experimenter. Those in one of these groups lapsed by smoking cigarettes containing the usual amount of nicotine. The other group was provided “denicotinized” cigarettes, containing negligible amount of the drug. A third group was not induced to lapse.

Subjects were monitored for a period of six days following their “lapse” (or no lapse) to determine how long it would take for them to spontaneously resume smoking. Results showed that those in the nicotine and denicotinized conditions did not differ in any significant way from one another. At the end of six days 45% of the nicotine group and 40% of the denicotinized group were still abstaining. This suggests that exposure to nicotine following smoking cessation might not be an important factor affecting relapse.

Compared to the two lapse groups, the no lapse group fared significantly better. At the end of the six days of follow-up 70% of those who had not been induced by the experimenter to lapse were still abstaining from cigarettes. This finding supports the idea that conditioning, cognitive, and emotional factors may play a critical role in influencing people to relapse following a lapse in smoking cessation.

The finding that nicotine in cigarette smoke did not play an important role in the lapse to relapse process provides greater insight into the process by which many smokers fail in their attempt to abstain from smoking. As a clearer understanding of the elements of smoking relapse emerges from psychological studies like this one, clinical and health psychologists will be better able to design effective treatments to prevent the progression so many smokers make from lapse to relapse.