What is Cue Exposure Therapy?
Cue exposure therapy or CET is intentional exposure to drug-related use cues in order to more quickly extinguish and silence conditioned responses.[1]
A tool of modern drug treatment programs, should it be our tool too? Should we wait for time and life to bring nicotine use cues to us, or seek out and extinguish them?
For example, it's likely that conditioned use cues are associated with your daily work schedule or chores. We can fear and delay getting back to work or intentionally confront and target them for extinction.
Our problems are the same as those confronting researchers and drug treatment programs. What use-stimulus pairings have our subconscious established, and how do we create safe exposure opportunities that don't significantly elevate the risk of relapse?
Some potential use cues may be beyond our ability to reproduce, such as those associated with changing seasons, holidays, birthdays, weddings, or funerals. Others, such as early alcohol use are extremely risky and, if insistent upon confronting them, CET should be done in the safest environment possible.
In real-world use, CET is, at best, a partial tool. Although we have the ability to boldly and quickly reclaim most aspects of life, we need to accept that some use-conditioning will survive and occur when presented by time or circumstances.
Still, intentionally confronting and silencing as many as possible can foster intense confidence in our ability to eventually extinguish all use-conditioning.
Developing super recovery confidence demands the ability to distinguish between subconscious classical conditioning (an uncontrollable response) and conscious thought fixation (a controllable situation).
It isn't always easy. Even after nearly all of our subconscious use cues have been extinguished, it's normal and natural for our senses to notice old use situations. The difference is that with fixation we have substantial control of our mind's response.
Give it a try. Imagine and create a high-quality image of your favorite food, the most tempting you've ever seen. Picture it oozing and dripping with flavor. Can you smell it? Imagine that first bite. Savor the flavor and sense the "aaah" sensation that follows.
While I controlled the imagery, you controlled the intensity and duration of any desire felt. Unlike a cue triggered crave episode, you were totally free to stop at any time.
CET Effectiveness Effectively Unknown
How effective is CET in increasing success rates? Frankly, we don't yet know. While some studies find benefit,[2] others don't.[3] But don't let that discourage real-world consideration.
There are huge and obvious challenges in producing quality evidence of the brain's reaction when attempting to accelerate extinction of the new ex-user's unique set of crave triggers.
First, researchers need to begin by evaluating CET in studies populated by addicts dreaming of permanently arresting their dependency, not smokers briefly deprived of nicotine while being shown images of suspected cues, all of whom fully expect to smoke or vape again within hours or a few days.
Nor should CET studies involve participants whose appetite for nicotine is being satisfied by free replacement nicotine.[2] Researchers also need a control group that, at least initially (for the first round), mirrors and allows fair comparison to real-world cessation.
Billions at stake, pharmaceutical industry muscle has no choice but to resist meaningful research. What would be the financial consequences of news headlines from CET studies detailing how CET demonstrated efficacy for those going cold turkey but not for those vaping or using NRT, or a finding that chewing nicotine gum when experiencing a crave actually prevents cue extinction? [4]
Still, some findings make sense. Researchers discovered that younger smokers respond to CET better than long-term smokers.[5] Even there, maybe extinction is simply more noticeable. Younger users often have fewer nicotine use associations, with far fewer use associated memories.
Interestingly, CET, and intentionally trying to rapidly meet, greet and extinguish use conditioning is contrary to historic cessation lessons, the remnants of which are visible across the internet.
For example, the U.S. government's leading cessation booklet is 37 pages and called "Clearing the Air."[6] Page 9 tells readers to stay away from places smoking is allowed and stay away from people who smoke. The title of page 24 reads, "Stay away from what tempts you."
Readers are then told to "Stay away from things that you connect with smoking," like not sitting in your favorite chair or watching your favorite TV show. They're told to drive a different route to work or not drive at all and take the train or bus for a while.
How can we reclaim driving or our favorite TV program if taught to fear and avoid it?
Unfortunately, my government's primary cessation booklet is loaded with serious conflicts. For example, the title of page 9 reads, "Meet those triggers head-on." Sounds great, right! But then the first two sentences on page 9 state, "Knowing your triggers is very important. It can help you stay away from things that tempt you to smoke."
Well, which is it? "Meet those triggers head-on" or "stay away" from them? Clearly, it's wise to stay away from nonsense booklets such as "Clearing the Air," as they cloud it further.
Let me share one more glaring "Clearing the Air" conflict. Page 17 is entitled, "Medicines that help with withdrawal."
The page tells readers, "You may feel dull, tense, and not yourself. These are signs that your body is getting used to life without nicotine. It usually only lasts a few weeks." There are medicines that can help with feelings of withdrawal: ... "nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch."
The obvious question becomes, how does the body get "used to life without nicotine" by feeding it "nicotine?" Obviously, it can't. It's as if health officials allowed Big Pharma to author the booklet.
Back to extinguishing use cues. What if you could extinguish some of your conditioned cues without experiencing any cravings? Actually, it's far more common than the neo-nicotine industry wants you to believe.
Research suggests that conscious thought and its subconscious influence have the ability to create new expectations conditioning capable of overpowering old use conditioning. Imagine your biggest recovery fear not triggering a craving.[7]
Again, think about how the single-session traveling hypnotist is able to briefly interrupt use urges and craves. It isn't magic. They relax our consciousness and then create new expectations.
And reflect on the subconscious impact of the title to Allen Carr's book "The Easy Way to Stop Smoking," and Joel Spitzer ending more than 100 articles and 500 video lessons exactly the same, by inviting us to "Never Take Another Puff."
The Opposite of CET: Delaying Extinction
Our conditioning patterns mirrored how we lived life. And we can't reclaim life by avoiding it.
A 2002 study found that 97% of inmates forced to stop smoking while in prison had relapsed within 6 months of release.[8]
When arrested, nearly all were actively feeding nicotine addicts. Once released, imagine their first time driving a car, walking into a bar, running into an old smoking buddy, or the moments following romance.
They were hit head-on by conditioned nicotine use cues associated with a host of situations that their arrest and imprisonment had prevented them from extinguishing.
As the correct portion of "Clearing the Air" states, "meet those triggers head-on." They mark the path home. Yes, you may find that there are some aspects of life that you no longer desire, but that will be your choice.
But do so safely. Consider breaking bigger challenges down into smaller tasks. Have multiple crave coping strategies ready, and don't hesitate to deploy another if your first choice isn't working.
And remember, if any situation begins feeling too threatening, simply walk away, and live to fight another day.
References:
2. Unrod M. et al, Decline in Cue-Provoked Craving During Cue Exposure Therapy for Smoking Cessation, Nicotine & Tobacco Research, March 2014, Volume 16(3), Pages 306–315.
3. Pericot-Valverde I, et al, A Randomized Clinical Trial of Cue Exposure Treatment Through Virtual Reality for Smoking Cessation, Journal of Substance Abuse Treatment, Jan. 2019, Volume 96, Pages 26-32.
4. Powell GL, et al, Nicotine Reduction Does Not Alter Essential Value of Nicotine or Reduce Cue-Induced Reinstatement of Nicotine Seeking, Drug and Alcohol Dependence, April 25, 2020, 5;108020, online ahead of print.
5. Traylor AC, et al, Assessing craving in young adult smokers using virtual reality, The American Journal on Addictions, Sep-Oct 2008, Volume 17(5), Pages 436-440.
6. National Institutes of Health, Clearing the Air, April 2003, NIH Publication No. 03-1647.
7. Dols M, et al, Smokers can learn to influence their urge to smoke, Addictive Behavior, Jan-Feb 2000, Volume 25(1), Pages 103-108.
8. Tuthill RW et al, "Does involuntary cigarette smoking abstinence among inmates during correctional incarceration result in continued abstinence post release?" (poster). 26th National Conference on Correctional Health Care, Nashville, Tennessee, October 21, 2002.
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