It Only Gets Better: a Comment on Schlam et al.
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INVITED COMMENTARY
It Only Gets Better: a Comment on Schlam et al. Peter S. Hendricks, Ph.D.
Published online: 15 September 2012 # The Society of Behavioral Medicine 2012
According to a leading theory of addiction [1], the relief of negative affect induced by drug abstinence (i.e., withdrawal) forms the motivational basis of chronic substance use. From this perspective, smokers, like other addicted individuals with their drug(s) of choice, learn through repeated pairings that cigarette use mollifies unpleasant mood states. In time, tobacco use becomes a primary means for coping with these aversive states. An important question emanating from this influential theory is whether chronic substance users can learn to manage negative affect, which is common to all human experience, without the use of their preferred drug(s). Schlam et al. [2] offer an intriguing first response to this crucial question. The authors found that, in a randomized clinical trial of smoking cessation, those who successfully quit smoking reported less craving and restlessness and fewer stressful events 1 year after they stopped using cigarettes than when they smoked. This research suggests that smokers can indeed learn to cope with negative affect without their drug of choice. Of course, learning to manage negative affect without cigarettes may be why smokers achieve long-term abstinence. But whether abstinence reduces withdrawal or P. S. Hendricks (*) University of Alabama at Birmingham, Birmingham, AL, USA e-mail: [email protected]
the reduction of withdrawal produces abstinence, these results gel nicely with contemporary theory [1]. The results of Schlam et al. provoke a number of questions for future study. Some clinicians may be resistant to the findings of Schlam et al. given anecdotal reports of craving persisting for years after cessation. Could there be a minority of former smokers who continue to struggle with negative affect well after they have achieved abstinence? And how do long-term former smokers react in the face of extraordinary but often inevitable stressors (e.g., the death of a loved one)? Some long-term former smokers do indeed relapse to cigarette use—might elevated withdrawal (e.g., depressive symptoms following the death of a loved one) be the culprit in such cases? The results of Schlam et al. provide a valuable glimpse into life before and after quitting smoking. It would be beneficial to add to this longitudinal observation life prior to the initiation of cigarette use, as well as life that never involved cigarettes at all (i.e., never-smokers). This would allow, among other things, for the evaluation of the longterm effects of tobacco use on addictive processes. Researchers may choose to supplement self-reported withdrawal with measures of brain activation and morphology focused on the limbic system and other regions relevant to addiction (e.g., the executive system, see [3]). Also, the adoption of the research paradigm of Schlam et al. to studies of other addictive behaviors would help extend the authors' finding
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