Animation by Robert Hood / Fred Hutch
Brien Thane started smoking as a teenager in the 1970s – and swore he’d quit if cigarettes ever cost $1 per pack. Then Thane promised to kick the habit before he turned 40. But by 2010, he was 53 years old and had never stayed off cigarettes for more than three weeks, even though he’d tried everything – from counseling to nicotine patches to prescription drugs – to stop his cravings.
Then Thane was invited to test a new smoking-cessation program developed by Dr. Jonathan Bricker of Fred Hutchinson Cancer Research Center. It was different than anything Thane had ever tried. Instead of teaching him that his cigarette cravings were enemies to be conquered, the new method taught him to mindfully accept his urges – and let them pass.
“It was like ‘Zen and the Art of Quitting Smoking’,” Thane said. “And it worked.” Thane hasn’t picked up a cigarette in the three-and-a-half years since he completed the clinical trial. It’s a huge accomplishment for someone who smoked a pack a day for more than three decades – and a sign of how Bricker’s research could revolutionize smoking cessation for millions of people struggling to quit.
Part visionary scientist, part creative psychologist, Bricker and his team are building smoking-cessation programs around an innovative approach – called acceptance and commitment therapy, or ACT – and delivering them via everything from group therapy sessions to a website to a new smartphone app.
Preliminary studies show that Bricker’s programs are 50 to 300 percent more effective than traditional approaches. And evidence suggests the ACT model could help adults cope with many other addictions and harmful behaviors.
“It was like ‘Zen and the Art of Quitting Smoking.' And it worked."
- Brian Thane, study participant
“It could be the missing link that finally drives down smoking rates,” Bricker said, “and it might be a better way to overcome obesity and alcoholism, and prevent the health problems that go with them.”
Other experts agree Bricker’s program could be transformative.
“Dr. Bricker’s ACT approach is a breakthrough in behavioral research and has major public health implications for the major causes of preventable death,” said Dr. Sean David, a leading tobacco-cessation researcher at Stanford University.
Challenging the status quo
In the 50 years since public health officials started a national anti-smoking effort, they’ve made tremendous progress in preventing younger generations from starting the habit but have a long way to go in helping smokers quit.
About 20 percent of Americans smoke and the best smoking-cessation programs only work for 10 to 15 percent of those who try them, despite a number of concerted efforts: Taxes have driven the price of cigarettes to around $7 a pack. Movies and television shows don’t glorify smoking anymore. Awareness campaigns teach kids about smoking’s dangers.
In the United States, lung cancer is responsible for more deaths than any other cancer, and it kills more men and women than breast, colon and prostate cancers combined, according to the American Lung Association. The majority of lung cancers are related to smoking, and the lack of effective programs to help smokers quit was one reason Bricker was so intrigued by ACT when he first learned about it at a 2004 workshop.
Photo by Robert Hood / Fred Hutch
Developed by Dr. Steven Hayes of the University of Nevada, ACT isn’t aimed at smoking. It’s a general approach that encourages people to step back, notice the thoughts and cravings that lead to destructive behaviors, and accept them. ACT teaches that if you don’t act on these urges, they will fade away. This creates space to commit to the core reasons you want to change your behavior.
When Bricker attended the workshop, he was working under Fred Hutch’s Dr. Art Peterson, testing a program that delivered traditional smoking-cessation programs over the phone. This meant using motivational counseling to inspire smokers to quit, and teaching them to avoid the people, places and activities that triggered cravings. When urges did strike, smokers were taught to distract themselves. This approach worked for about 10 percent of those who were smoking daily when they started the trial.
“I had a hunch that ACT could be a better solution, and that it was definitely worth testing,” Bricker said.
This willingness to challenge the status quo drives many scientific advances. Still, Bricker knew it was going to be hard to land the millions of dollars he would need for clinical trials to evaluate ACT. The theory was too new, too untested and too contrary to what everyone believed.
“To most people in my field, the idea of teaching people to accept their cravings seemed far-fetched and naïve,” Bricker said.
But Dr. Ross Prentice, who was then head of the Hutch’s Public Health Sciences Division, took a chance in 2008 and, along with his executive committee, awarded Bricker a small grant to do a pilot study. It’s a tried-and-true approach: use private dollars for small studies that test new ideas. Bricker knew it was his best shot at seeing whether ACT could be effective.
“If we were ever going to get federal funding,” he said, “we knew we would need solid pilot data that addressed every big question and critique.”
‘I was stunned’
Piece by piece, Bricker’s team built their case. They translated ACT, which is an abstract concept, into a straightforward program that would make sense to the general public. Then, for the pilot study, they created the first telephone-delivered smoking-cessation program based on ACT. In 2009, they found that 29 percent of that study’s participants quit smoking for at least a year.
Then Bricker collaborated on a trial that delivered ACT via group therapy sessions. Fully 30 percent of participants stayed off cigarettes for a year, compared to 13 percent of people who followed the traditional intervention.
“That’s when I knew this could actually work,” Bricker said.
Still, Bricker’s applications for National Institutes of Health funding fell flat. But he stayed the course, his research supported by funding from private donors, and kept generating promising results until 2010, when the NIH finally gave him a high score on a proposal to test the group therapy approach. It was a five-year, $3.2 million grant, and the score meant it was sure to be funded.
Bricker had been rebuffed so many times that he didn’t believe the money would come through – until months later, on a hot June afternoon in the Reno, Nev., airport. Bricker had just spoken at a conference and was waiting for a flight to Seattle. All around him, gamblers fed coins into slot machines. Bricker checked his email and saw one from the NIH, notifying him that the first payment was about to be transferred to Fred Hutch.
“It was my own jackpot,” Bricker said, “and I was stunned – just stunned – that we were going to pull this off.”
That study is now in its fourth year and Bricker has conducted three more clinical trials. Thane participated in one of them and attended group therapy sessions at Group Health Cooperative, one of Bricker’s research partners. Thane, who develops housing for low-income people, remembers the instructor telling him to imagine he was driving a car and that his urges were backseat drivers. Then, whenever Thane had an urge to smoke, he would remember he was the one in control, and he would recommit to his reason for quitting: to be healthier so he could enjoy every aspect of his life, including sailing the 22-foot boat he keeps docked near his home in Bellingham, Wash.
He still remembers the day he quit for good. He was leaving a barber shop when he ran out of cigarettes.
“I started toward a convenience store, then I stopped and said ‘for crying out loud, who’s driving this car’,” Thane said. “Then I turned around and headed for my boat.” Thane hasn’t smoked since, and other people in the study have had similar success.
In a recent paper, Bricker’s team reported that 31 percent of participants quit for at least six months, compared to 22 percent of people who followed a traditional approach. People who smoked more than a pack a day did the best – 36 percent of them quit for at least six months, versus just 17 percent of those in the control group.
“In some cases, the ACT approach is more than twice as effective as traditional interventions,” Bricker said. “It shows how powerful this could be.”
"If we can offer an effective app and an alternative to smokefree.gov, we could potentially save many, many people from lung cancer and other diseases.”
- Jonathan Bricker, Ph.D.
Do-it-yourself smoking cessation
Bricker knows that in-person quit counseling is increasingly out of step with a world where many people prefer do-it-yourself approaches they find online. There are more than 400 quit-smoking apps on the market and the federal government’s online smoking-cessation site, smokefree.gov, attracts more than 1.5 million visitors a year. None of those apps are backed by research that proves they work, and only about 10 percent of smokefree.gov users quit for more than a month.
“We have to do better,” Bricker said. “There are just too many people who might never have access to standard counseling, especially in rural areas where people are far more likely to smoke.”
In 2010, Bricker’s team tested a potential solution: WebQuit, a free website that guides smokers through ACT-based approaches. WebQuit helps users develop personalized quit plans, offers tutorials that teach people to allow their cravings to fade away, and lets users upload photos of their families, favorite places, and anything else that illustrates their commitment to quitting.
After pilot research showed WebQuit is more effective than smokefree.gov, Bricker used the results to land another five-year, $3.2 million NIH grant to improve the site and launch randomized clinical trials. His team recently showed that 23 percent of ACT participants quit for 30 days, versus 10 percent of participants in the control group.
Photo by Robert Hood / Fred Hutch
Now Bricker’s team is working with Seattle-based companies Blink Interactive Inc. and Moby Inc. to redesign WebQuit ahead of a Phase III trial. The goal is to open the site to the public – right now it’s only available to clinical trial participants – later this spring.
Bricker recently completed another pilot study that takes this research to the next technological level by testing a smartphone app – called SmartQuit – that his team developed with help from Seattle-based 2Morrow Inc. The app has features like push notifications that invite users to watch video tutorials or track how well they accept their cravings. Bricker is waiting to hear from the NIH about a grant to test the app on a larger scale.
He envisions day when it gives millions of smokers a better way to quit.
“If we can offer an effective app and an alternative to smokefree.gov, we could potentially save many, many people from lung cancer and other diseases,” Bricker said.
Surprising results, new directions
As Bricker’s team evaluated the data, they noticed some surprising results that had nothing to do with smoking.
Smokers often gain weight and drink more alcohol when they quit. But in one Bricker study, participants who followed ACT lost an average of 9.2 pounds, while people in the control group gained nearly a pound on average. In that same study, only 11 percent of people in the ACT group reported they were drinking heavily after six months, compared to 22 percent in the control group.
Bricker thinks this might show that participants who learn ACT apply it in ways that extend far beyond smoking. That means the smoking-cessation studies are now a gateway toward exploring whether ACT can help people overcome obesity, alcohol abuse and other behaviors that increase their risk for cancers, heart disease and other serious health problems.
Bricker is teaming up with Fred Hutch’s Dr. Shirley Beresford to obtain funding for an ACT-based weight loss program, and he is joining forces with Dr. Jaimee Heffner, a staff scientist on his team, on an intervention to curb alcohol abuse.
“At least 40 percent of all cancer cases are caused by behavior, and we hope that ACT or a future innovation can help us change those behaviors and prevent those cancers,” Bricker said. “That’s part of what makes it so exciting.”
About the study
How the SmartQuit app works
There are more than 400 quit-smoking apps on the market. Bricker’s is the first to be clinically tested to see if it actually makes a difference.
Bricker’s team developed a smartphone app, called SmartQuit, that guides users through a do-it-yourself quit-smoking program.
The app includes video tutorials and a reward system that helps people overcome their cravings. It also sends “push” messages directly to users’ phones, congratulates them on their progress and reminds them to check in for help.
SmartQuit users stay motivated by tracking their progress and listening to inspiring stories. They even receive electronic “badges” to reward their hard work.
SmartQuit lets users upload photos of their family, special places, or anything else that illustrates their motive to quit.