When was your subconscious conditioned to expect a new supply of nicotine? Was an urge or craving triggered in the anterior cingulate cortex (ACC) region of your brain[1] upon smelling coffee, starting the car, placing a plate into the sink, the sound of a bottle or can opening, or ice cubes hitting a glass?
The problem with this topic is that while we each have a fair picture of the situations during which we found ourselves both using and not using, few have awareness of the precise cue, or cue combinations, recognized by our subconscious.
While researchers have conducted hundreds of what they call "cue reactivity" studies, until recently nearly all involved what they refer to as "proximal cues" (eg, pictures of cigarettes, lighters, or an ashtray with a lit cigarette). Only recently have they started studying the places or environments which generate cravings, and how proximal cues interact.[2]
What follows is a brief review of possible use-cue situations that may generate brief urges or cravings. Don't be intimidated. Use this list to reflect upon your own use patterns and possible cues. The more mindful of potential cues, the less frightened and unprepared you'll hopefully be.
As you read, imagine navigating each situation and claiming the prize at the end. Why fear extinguishing use cues? Get excited about it!
Proximal Cues
Our closest, most frequent, and possibly most intense urges were likely associated with nicotine use and use paraphernalia. Our five senses (sight, smell, taste, hearing and touch.) alert the brain that a proximal use cue has been countered.
The smoker's utensils include individual cigarettes (some dropped and hidden from view), packs (some misplaced and forgotten), lighters or matches, ashtrays, cartons, or loose tobacco and rolling-paper.
Aside from the e-cig device, the vaping addict's equipment inventory may include a backup, extra or refillable juice cartridges, flavorings, batteries, chargers, and possibly a carrying case. The smokeless tobacco user's arsenal may include tins, pouches, sleeves, rolls, logs, tubs or bags, and spit containers or locations.
The perceived opportunity to inhale nicotine increases craving and may itself be viewed as a conditioned cue.[3][4]
Proximal means nearest. For those just beginning their journey home, nearness means an increased likelihood of relapse. Researches have found that proximal cues "reliably evoke robust cravings."[2]
Don't play mind or strength games with nicotine. Instead, be smarter. Fully commit to success. Find and destroy, beyond salvage, the instruments of defeat.
Activities
Was your first morning activity trigger climbing out of bed, making it, getting dressed, caring for a pet, turning on the television, making or eating breakfast, making or drinking coffee or tea, finishing the dishes, sitting in your favorite chair, reading the paper, stepping outside or into the garage, brushing your teeth, watering plants, getting out of the shower or using the bathroom?
Imagine having so tied nicotine use to using the bathroom that, once use ends, you're briefly left wondering if you'll ever be able to have a bowel movement again.
Mandatory daily activities such as eating and sleeping compel us to quickly meet, greet and extinguish associated cues.
Do you have young children? If so, cues may be tied to (before, during or after) waking your children, feeding them, making lunch, getting them off to school, or dropping them off. Once home, there's homework, after school activities, chores, boo-boos, tears, illness, worry, tending to their daily needs, fixing dinner, baths, getting their clothes ready, bedtime, reading or singing them to sleep, and the brief period of quiet which follows.
There's housework, daily planning, caring for pets, talking on the phone, laundry, taking a break, paying bills, worry about paying bills, television, using the computer, walking outside, and gardening or yard work.
And don't forget the workplace. There, you may have conditioned yourself to see the need for nicotine replenishment as a reward (a "smoke break") for having accomplished some task.
Other work-related cues may have included traveling to work, arriving, either nicotine-use breaks or use while working, talking on the phone, deadlines, lunch, stress, the end of the workday, and catch-up replenishment while traveling home. Some of us had so tied nicotine-use to work that we can't imagine ever being productive again.
Delay in confronting and extinguishing work associated conditioning can be costly. Work avoidance can add mountains of needless pressure and anxiety to recovery. Why fear quickly silencing all work-related use cues and being rewarded with an urge-free workplace?
Be brave. Take that first step. Just that first brave step and the next one becomes easier.
Then there are possible cues associated with arriving home, reading mail and email, preparing dinner, the evening news, watching movies or Netflix, hobbies or leisurely activities, social time, caring for pets, preparing for bed, or romance.
As reviewed in Chapter 6, the only use-cues we suggest delay in encountering are associated with using alcohol or other inhibition diminishing chemicals. As there discussed, unless you have co-dependency concerns (also Chapter 6), alcohol use is a non-mandatory activity that can be delayed a few days, at least until you are beyond peak withdrawal.
As also reviewed in Chapter 6, alcohol can be associated with multiple use-cues, including the location, people present, the presence of cigarettes or other users, peer pressures, music, singing, relaxation, dancing, celebration or intoxication.
Locations
Think about the locations you frequented that may have become conditioned use cues: a yard, a park or community bench, entering the house, the bathroom or a work area, your smoking room, garage, backyard, the garden, outdoors, a vehicle, bus stop, train or subway station, a walkway, workplace, bar, pub or restaurant, or entering or leaving a store.
We encounter some use locations far more often than others. How often was use associated with entering or exiting your place of worship, a doctor's office or hospital, or in association with a movie, concert or sporting event? If we established associated use cues, when might they next be encountered?
People
We may have tied use with being around a specific friend, acquaintance, or co-worker, who may have been nicotine users themselves. If so, when will you next see them? And what about being around those who increased our anxieties. Just seeing them could trigger an urge.
And don't forget those who were not slaves to nicotine themselves, who tended to visit and stay longer than our unfed addiction could tolerate. What will happen immediately prior to their next visit, or as soon as they leave?
Times
Our most dependable and core use-cue is likely related to time, the fact that unless replenished, our body's nicotine reserves decline by roughly half every two hours.
My level of tolerance was chain-smoking 3 packs-a-day (60) for the final 5 years If standing perfectly still, my next urge was never more than 15 or so minutes away.
Other specific time use-conditioning could be related to waking, meal or break-time, or related to the hours or minutes appearing on a clock or watch. Cues could be associated with the time that our workday ends, a television program, or the time when we begin getting ready for bed.
Times of the year may serve as conditioning: a vacation, spring and blooming flowers, arrival of summer heat, fall's cooler temperatures, falling leaves, that first frost, winter or snowfall.
But don't be surprised if by then your crave generator seems to have lost its punch. Instead of full-blow cravings, remote, infrequent or seasonal cues may by then feel more like a few seconds of stiff breeze.
Eventually, the time and distance between remote un-extinguished use cues will become so great that any breeze is barely noticeable or even laughable. They'll become a long-overdue reminder of the amazing journey you once made.
Events
There were some events that served as cues for most of us. Research has found that seeing and smelling a burning cigarette will cause a cue-induced craving during early recovery.[5] Would watching another oral tobacco user put tobacco into their mouth trigger a craving in most oral users? Probably.
Weddings, funerals, the birth of a baby and offer of a cigar, holidays, birthdays, and New Year's reflect infrequent cue possibilities. If so, recovery is about extinguishing each and reclaiming all aspects of life, just one opportunity at a time.
The smell of morning coffee, seeing a smoking friend, hearing laughter, tasting your favorite drink, touching your nicotine delivery device, wouldn't it be fascinating to have a full and accurate awareness of all nicotine use conditioning while navigating recovery?
Although conventional wisdom suggests that we attempt to discover our cues beforehand, frankly, even when we think we've identified the exact cue adopted by our subconscious, we'll often miss the mark. Instead of frustrations associated with being unable to accurately predict subconscious cues, it's probably best to remain calm yet fully prepared to react on a moment's notice.
Emotions
As detailed in Chapter 10, the range of human emotion provides the subconscious with a vast spectrum to pick from. Laughter, sorrow, a sense of accomplishment or defeat, worry or calm, each has the potential to generate a craving if the mind created a use association.
Extended emotions such as financial strain, a serious illness or injury, a bad relationship, or the death of a loved one, were ripe for cue establishment. What would each be like without addiction to a stimulant making the heart pound faster?
Encountering More Than One Cue
As a new ex-user, just four days free, imagine visiting a local pub and taking a seat on an outdoor patio that's filled with smokers. After an extremely stressful workday, you order your first drink, all the while suspecting that tomorrow may be worse. And then it happens, an immediate and larger than life urge to bum a smoke.
How many different use cues could get triggered?
A 2014 study found that (1) drinking alcohol while (2) experiencing a negative mood (feeling irritable, sad, anxious, tense, stressed, angry, frustrated) while (3) being around other smokers, generated a more intense crave episode than generated by encountering any individual factor or any two paired factors.
I share this, and what follows, not to scare you but to hopefully motivate you to continue reading this chapter. I encourage you to think through and adopt multiple crave coping strategies and to be prepared to immediately call upon as many necessary to keep nicotine from entering your body.
Early Withdrawal
Overlaying operant conditioning atop classical conditioning, atop physical withdrawal, atop emotional recovery, atop loads of junkie thinking fueled by the collective tease of thousands of old replenishment memories, is it any wonder that, for some, the initial 72 hours may feel intense?
Relax. Whether letting go turns out to be a cakewalk or your greatest challenge ever, why fear healing? The good news is that we move beyond peak withdrawal within three days. The good news is that, by then, most have extinguished many of the cues associated with life's most basic and frequent activities: breathing, waking, dressing, walking, talking, eating, working and sleeping.
It's why watching pharmaceutical companies sell expensive products that drag withdrawal out for weeks or months is so disturbing. And how does popping a piece of nicotine gum or a nicotine lozenge into our mouth when a use-cue is encountered extinguish conditioning? Add in products like Chantix/Champix, which come with serious or even life-threatening risks, it makes you wonder whose interests are being protected.
We are each unique when it comes to the number and types of use cues we established. Although natural to want to run and hide from conditioning, extinguishing each and reclaiming life is what freedom is all about. Embrace coming home, don't fear or fight it.
References:
2. Conklin CA et al, Combined smoking cues enhance reactivity and predict immediate subesquent smoking, Nicotine & Tobacco Research, 2019, Pages 241-248
3.Wertz JM and Sayette MA, A Review of the Effects of Perceived Drug Use Opportunity of Self-Reported Urge Experimental and Clinical Psychopharmacology, Feb 2001, Volume 9(1), Pages 3-13.
4. Cortese BM et al, Olfactory Cue Reactivity in Nicotine-Dependent Adult Smokers, Psychology of Addictive Behavior, March 2015, Volume 29(1), Pages 91-96.
5. Niaura R, et al, Individual differences in cue reactivity among smokers trying to quit: effects of gender and cue type, Addictive Behavior. Addictive Behaviors, March-April 1998, Volume 23(2), Pages 209-224.
6. Lam CY, et al, Individual and combined effects of multiple high-risk triggers on postcessation smoking urge and lapse, Nicotine and Tobacco Research, May 2014, Volume 16(5), Pages 569-575. https://pubmed.ncbi.nlm.nih.gov/24323569/
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