Freedom from Nicotine - The Journey HomeThe Unconscious Mind
Endlessly hammered by flavor, aroma, pleasure, friendship, adventure, rebellion and affordability marketing, our subconscious was the nicotine addiction industry's subliminal message board. Twice the traveling hypnotist sold me a couple of days of unbelievable hypnotic bliss before I tested it and relapsed.
But looking upon our unconscious mind only in terms of being the playground of others cheapens and makes it look dumb, while ignoring our conscious ability to retrain it. Even here, if so dumb, why can our subconscious see subliminal messages invisible to the conscious mind or feel the influence of tobacco marketing that our consciousness thinks has been ignored? Why can it react to triggering cues written upon it by hypnotic suggestion, cues meaningless to conscious awareness?
Dumb? When typing on a keyboard, what part of the mind and level of awareness is thinking about, locating and striking the correct key? While operating a vehicle, who is really controlling which foot needs to push on which peddle and how hard, or doing the driving as we read billboards, talk on the phone or daydream?
Our conscious mind has unknowingly aided in teaching our subconscious skills and how to perform activities, including use nicotine. Now it's time to knowingly teach it how to function without it.
Whether referred to as our subconscious, unconscious or preconscious, science is still in the early stages of discovery in understanding the scope of its involvement in day-to-day life. But it's every bit as real as the never seen portion of an iceberg. Think of Disney World and awareness of the magic above ground, while an unseen city beneath brings the magic to life.
It is normal for us to deeply believe that our consciousness is the one doing things, that it causes our actions after careful deliberation, that our behavior was our idea. While this is our self-perception, a growing body of evidence suggests that like Disney's puppets, the conscious mind is not the primary source motivating behavior, that our subconscious has already made up our mind for us.
It's suggested that the unconscious mind has evolved as a highly adaptive "behavioral guidance system" which acts on impulse. It's increasingly believed that the impulse for behavior flows from our subconscious, that our consciousness then seizes upon the idea as its own, and that the real role of our consciousness is as impulse gatekeeper, and trying to make sense after the fact of behavior that it allowed to occur.
Sources of subconscious impulses can include evolutionary motivations, past personal preferences, cultural norms, family values, past experiences in similar situations, how others in the same situation are currently behaving, or be the product of conditioning, both reinforcement (operant) and association (classical).
Multiple sources of subconscious behavioral impulses make conflicts inevitable. Drug addiction reflects a conflicts war zone. Our subconscious has its own behavioral goals, goals hidden from awareness. Reading these words is clear evidence that "you" want to break free. It's likely your subconscious does too. But after conditioned by years of nicotine dependency rewards, punishment and associations, it could use your help in coming home, a little teamwork.
Reinforcement & Crave Episodes
Operant conditioning - Operant conditioning is a process that operates to modify behavior (in our case nicotine use) through positive or negative reinforcement (dopamine aaahs or anxieties of early withdrawal), so that we come to associate the pleasure or displeasure produced by the reinforcement with the behavior.
Drug use behavior conditioning reflects unintended expectations training of the subconscious mind. Hundreds or thousands of annual nicotine use repetitions created strong unconscious associations between using nicotine and the adrenaline stimulated dopamine "aaah" sensations that followed.
Operant conditioning associated with "aaah" pleasure seeking alone was only one aspect of subconscious control. We were also controlled by displeasure and fear conditioning associated with the consequences of ignoring nicotine's two-hour half-life. Once hooked, we quickly discovered that delaying replenishment for too long made us anxious, irritable and depressed our mood.
Like being beat with a whip or receiving an electrical shock, the anxiety consequences of having waited too long between feedings operated to condition us to void anxieties by engaging in replenishment early and often.
Trapped in a perpetual cycle between emotional beatings and dopamine rewards, is it any wonder that both our subconscious and conscious grew to deeply believe that nicotine use defined who we were, that replenishment was as important as eating, and that life without it would be boring, empty or nearly impossible?
The good news is that within 72 hours of ending nicotine use the subconscious has no choice but to begin noticing that peak withdrawal has been achieved, and is now gradually beginning to subside. While likely still anxious and alert, the most intense period of recovery is over. So long as all nicotine remains on the outside, fears and anxieties associated with the onset of withdrawal will never be encountered again.
While negative reinforcement operant conditioning is quickly snuffed-out and extinguished by diminishing punishment for not using nicotine, the behavioral influence of "aaah" memories associated with positive reinforcement take time to overcome.
The good news is that while we can't erase "aaah" memories, conscious honesty and dependency understanding enable us to see them for what they truly reflect, an endless string of mandatory replenishments during active drug addiction. Recasting them in truthful light can diminish or destroy their current influence upon us.
But even if we go years without nicotine, the effects of just one powerful puff, dip, chew or hit somehow revives old "aaah" memories, positive reinforcement operant conditioning and, whether wanted or not, soon has the subconscious begging for more. Although not always easy, the solution will always remain simple ... no nicotine today!
Classical conditioning - As it relates to nicotine, classical or Pavlovian conditioning is conditioning in which a person, place, thing, activity, time or emotion (a conditioned stimulus or use cue) becomes so paired with and precedes using nicotine, until encountering the conditioned use cue alone becomes sufficient to trigger urges and cravings for nicotine.
Subconsciously triggered anxieties are the mind's means of commanding that we once again bring nicotine into our body. Like Pavlov's dogs, which he conditioned to expect food and begin salivating upon the ringing of a bell, we each conditioned our subconscious to expect arrival of a new supply of nicotine in specific situations.
Researchers have successfully used sight, smell and hearing to establish new conditioned use cues in smokers. Encountering the new cue triggered use expectations and an urge to smoke, with an increase in pulse rate. Researchers found it easier to establish new cues among light smokers, who obviously had fewer existing cues than heavy smokers.
If crave episodes feel real and physical in nature there's good reason. Although nicotine-feeding cues are psychological in origin, they trigger physiological responses within the body and mind. Not only does using nicotine increase pupil size, researchers found that encountering a visual nicotine use cue will increase pupil size, an autonomic response.
Using brain scans, researchers discovered increased blood flow during cue-induced cravings in the brain's ventral striatum, amygdala, orbitofrontal cortex, hippocampus, medial thalamus, and left insula, regions associated with aaah rewards and anxiety. They also found that the amount of blood flow (perfusion) positively correlated with the intensity of the cue induced cigarette cravings in both the prefrontal cortex and the posterior cingulate, regions known to control attention, motivation and expectancy.
Years of subconscious conditioning had us reaching for a nicotine fix and conducting replenishment without recognizing that our mind had sensed a cue (conditioned stimulus), and often without realizing that replenishment was underway.
Study the next smoker you see. As if on autopilot, it is very likely that the drags we'll watch being inhaled will be taken while their unconscious mind is in full control. I can't begin to count the number of times I looked down and was forced to explain why the ashtray was full and the pack empty.
Our dependency's level of nicotine tolerance (the amount of nicotine required daily in order to overcome acetylcholine receptor up-regulation and desensitization), combined with nicotine's half-life to compel each of us to decide when during each day we would engage in replenishment in order to avoid experiencing early withdrawal anxieties.
Possibly unaware we were doing so, we each established daily replenishment patterns that taught and conditioned our subconscious when to expect more nicotine. It was watching and remembering as use cues arriving via sight, smell, sound, taste, touch and emotions were quickly followed by arrival of new nicotine.
Crave episode Intensity - As we navigated our day, our subconscious recognized use cues and issued gentle commands letting us know it was again time for replenishment. Sometimes the urges were noticeable and sometimes not. If replenishment was overdue, they could arrive as full-blown crave episodes. Recent findings suggest that the insula, in the brain's limbic region, may act as a control center able to alter the intensity of anxiety commands in response to encountering a time, place, location or emotion during which we had conditioned our subconscious to expect nicotine.
The intensity of a particular crave episode appears to be influenced by a number of factors. A 2007 general substance dependence study found that, across genders, the two most significant crave intensity factors were how recently the person had used their drug, and their level of impulsiveness.
It makes sense. The longer without nicotine, the more intense the subconscious command, at least until the mind begins to notice withdrawal peak and begin easing off. It's here that it has no choice but to begin an awakening to the realization that nicotine addiction is about living a big fat lie, that once all nicotine is out of our system, things slowly start getting better not worse.
As for impulsivity, it is the trait that caused many of us to "experiment" with nicotine in the first place. Now the same trait that enslaved us breeds extra anxieties when forced to be patient and ignore the prospect of instant "aaah" gratification.
If impulsive, focus upon the much bigger but delayed reward. Think about at last being free from gratification compulsions associated with endlessly declining nicotine reserves. Why can't impulse be put to work in reclaiming freedom, pride and self-esteem?
Imagine the creation of healthy, positive impulses that instantly respond to protect us from challenge, as though a firefighter arriving on the scene with quality flame controlling tools. There is no classical nicotine use conditioning that cannot be extinguished, no aspect of life that cannot be reclaimed.
The same 2007 study also noted that the level of depression among women, but not men, was capable of impacting crave episode intensity. Get seen and get help if depression has you on the brink of relapse Place a physician skilled in treating depression on your recovery team. Don't use it as an excuse to continue use of the very chemical that likely contributed to causing depression in the first place, a super-toxin that will only make it worse.
A food craving study found that vividness of imagery associated with food influenced craving intensity. Go ahead. Give it a try. Picture your favorite food. Now make the mental image as vivid and detailed as possible. Feel the urge? Now picture your particular nicotine delivery device, picture the brand, and imagine holding it. Feel the urge?
Why not use recovery imagery as a subconscious re-training tool? Why not flash our own subliminal messages? Picture yourself engaging in every activity during which you used nicotine but comfortably doing so without it. See yourself doing each activity as well as or better. Picture an entire day without once wanting nicotine. Imagine a full day without any addiction chatter. See such days becoming more and more frequent, until becoming your new sense of normal. Think about the beauty of your brain responding to life instead of nicotine.
Controlling expectations - A 2001 classical conditioning smoking study taught us two important lessons about the influence of conscious expectations upon cravings. Smokers were educated to expect to be able to smoke during a specific situation (cue) and encouraged to identify the situation when it occurred. Researchers found that upon encountering and noticing the smoking cue that the intensity of cravings increased. They noted increased salivation, skin conduction and increased craving in answers to crave assessment questions. Amazingly, their craving responses were eliminated after retraining them not to expect to be able to smoke when the cue was encountered.
The lesson that conscious expectations can control both subconscious expectations and cravings is critical. It means that what we think and believe is critical, that we can be what we expect.
Think about the traveling smoking cessation hypnotist using their conscious mind to relax our conscious mind, so as to allow them to rewrite subconscious expectations. The problem with single-session cessation hypnosis isn't that it does not or cannot work, at least briefly. It's that it only addresses a single aspect of recovery on a single occasion, the subconscious, while ignoring the ongoing negative influence of conscious stimulation and years of nicotine use related thoughts.
Think about the repeated subconscious impact of the title of Allen Carr's book "The Easy Way to Stop Smoking." Each time the book is opened the subconscious is hit with the message that stopping can be easy. Inside, Allen does the same thing Joel does in the first two chapters of his free PDF electronic book "Never Take Another Puff, and shared here in Chapter 3, invite the enslaved mind to see through the lies our addiction forced us to accept.
We don't need to be trained hypnotists to use our conscious mind to calm, reassure, sooth or create subconscious expectations. Draw near and talk to it, it's listening. Try engaging in slow deep breathing while progressively relaxing your body. Quiet all chatter inside your mind by focusing to the exclusion of all other thought upon an image of your favorite place. Once relaxed, it's time to change expectations.
Reassure your subconscious. Let it know there is absolutely nothing to fear in coming home to entire days where we never once think about wanting nicotine. Teach it that contrary to the lies, everything we did while slaves can be done as well as or better once free. Encourage your subconscious to join forces in embracing recovery, that challenge is good not bad as it reflects true healing. This is the greatest period of healing our brain has likely ever known. Help the unconscious mind bask in freedom's glory. Invite it to feel the delight of ongoing victory and mounting self-esteem.
Deep relaxation may be challenging during the first 72 hours. If so, think about how relaxed the conscious mind and body become immediately prior to slumbering off into sleep. Seize upon and use these precious seconds when our conscious and subconscious draw near. Calm subconscious fears as you slumber into sleep. Throw out the lies. Celebrate today's victory and picture tomorrow being your most fruitful day of recovery yet. Slide off into sleep feeling free and proud.
Common Use Cues
When during each day did our subconscious expect nicotine? Was its cue the smell of morning coffee, the feel of placing our dinner plate into the sink, or the sound of a bottle or can opening, or ice cubes filling a glass? While few of us appreciated the precise cue recognized by our subconscious, we have a pretty good feel for most situations during which we engaged in replenishment.
Activities - Each of us had conditioned our mind to expect nicotine in association with certain activities. Our morning activity triggers may have been associated with climbing out of bed, making the bed, getting dressed, caring for a pet, surrounding breakfast, reading the paper, drinking coffee, stepping outside, brushing our teeth or even using the bathroom. Imagine so tying nicotine use to using the bathroom that once use ends we are briefly left wondering whether we'll ever be able to have a bowl movement again.
If parents, cues may be associated with waking your children, feeding them, or getting them off to school. Housework, daily planning, talking on the phone, taking a break, television, using the computer or walking outside. While necessary that the children get off to school during early recovery, a lack of nicotine induced "aaah" rewards may combine with a fear of encountering crave triggers to cause postponement of non-essential activities such as housework, but often not without a price.
A dirty house or tall grass may breed their own escalating internal anxieties or cause needless family frictions. But initially, without our drug, conditioning can make a task seem worthless or even impossible.
And then there's the workplace where nicotine replenishment may have been associated with rewards for having accomplished work tasks. Travel to work, arriving, either nicotine-use breaks or using while working, the end of the workday, travel home, some of us so tied nicotine use to work that we can't imagine ever being able to be productive workers again. Delay in confronting and extinguishing work associated conditioning can add needless pressure and anxiety to recovery. Take that first step, just a tiny one, and the step that follows becomes easier.
Then there are possible cues associated with arriving home, preparing dinner, the evening news, hobbies, leisurely activities, preparing for bed or having sex. Mandatory activities such as eating and sleeping compel us to quickly meet, greet and extinguish any associated cues. In fact, extinguishing eating cues early, at a time of diminished "aaah"s, can have us consuming greater quantities of food in an attempt to replace missing nicotine "aaah"s with food "aaah"s. Obviously, using additional food as a crutch brings potential to create weight gain anxieties.
The only use cues we encourage delay in encountering are associated with using alcohol or other inhibition diminishing chemicals. Unless we have co-dependency issues, these are non-mandatory activities that can be delayed for a few days, at least until though the most challenging portion of recovery. Even then, there can be multiple cues related to alcohol use, including the location, people present, the presence of cigarettes or other users, and celebration. It may be best to break them down into smaller challenges.
Locations - Think about the locations you frequented that may have become conditioned use cues. Entering the house, bathroom, work area, your smoking room, garage, backyard, the garden, outdoors, a vehicle, bus stop, bicycle, walkway, workplace, bar, pub or restaurant, or entering or leaving a store.
We used nicotine in some locations more than others. How often did we use in association with a place of worship, a doctor's office, a hospital, movie theater or concert? If we established cues, when might they next be encountered?
People - We may have established cues associated with specific friends, acquaintances or co-workers. If so, when will you see them next? Then there are those people whose personalities somehow increased our anxieties. Just seeing them could trigger a craving. And don't forget those who didn't use nicotine and tended to visit and stay longer than our unfed addiction could tolerate. What will happen the next time they visit and then leave?
Times - Conditioning could be associated with waking, mealtime or break-time. Cues could be related to the hours or minutes appearing on a clock or watch. They may be associated with the time that our workday ends, a television program or the hour when its time to prepare for bed. Times of the year may serve as conditioning: spring and blooming flowers, arrival of summer heat, fall's cool temperatures, falling leaves, winter or that frost. But don't be surprised if by then your crave generator seems to have lost its punch. Instead of full-blow cravings, hopefully it'll be more like a few seconds of stiff breeze. Hopefully, lengthy and still growing periods of calm between challenges will make entertaining the suggestions posed by a remote triggers seem almost laughable.
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. Would watching another oral tobacco user put tobacco into their mouth trigger a craving in most oral users? Although no studies, I wouldn't be surprised.
Weddings, funerals, the birth of a baby and offer of a cigar, holidays, birthdays, New Year's, recovery is about taking back our life, just one piece 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 full and accurate awareness of all nicotine use conditioning prior to commencing recovery?
Although conventional wisdom suggests we attempt to discover our cues beforehand, frankly, even when we think we've identified the exact cue adopted by our subconscious, we 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 - The range of human emotion is tremendous, as is the subconscious mind's ability to use our spectrum of emotions as feeding cues. Laughter, sorrow, a sense of accomplishment or defeat, worry or calmness, each is there for the taking.
Ongoing emotions such as those associated with financial strain, serious illness, injury, or the death of a loved one, were ripe for cue establishment.
Withdrawal cues - Overlaying operant conditioning expectations over craves associated with classical conditioning, atop physical withdrawal and emotional recovery, brings potential to foster a somewhat intense initial 72 hours.
Achieving peak withdrawal within 3 days, the "real" battle against physical addition is over within a matter of hours. It's why watching pharmaceutical companies sell expensive products which drag withdrawal out for weeks or months is so disturbing. Add in products like Chantix (or Champix), which has been linked to suicide and it makes you wonder whose interests government health officials are trying to protect.
The number and types of cues selected and formed by endless compliance with the mind's chemical demand for more, resulted in each person's list of cues being almost unique. Although natural to want to run and hide from conditioning, cues are our stepping-stones to reclaiming the activities of life.
Are crave episodes really less than 3 minutes?
Yes, within three minutes you should sense craving anxieties, anxiousness and/or panic peak and begin easing off. Although amazingly little research in this area, it is a recovery lesson widely taught across the Internet and shared both at WhyQuit and Freedom from Tobacco.
While possible that more than one un-extinguished subconscious cue may be may encountered within minutes of each other, years of online discussions suggest it isn't as common as we might think. What we do see now and then are descriptions of conscious thought fixation, which, like concentrating on your favorite food or fantasy, can last as long as the conscious mind has the ability to maintain concentration and focus.
The primary distinction between the two is control. While we have substantial direct control over the duration of conscious thought fixation, and significant control over how the conscious mind reacts when a subconscious cue is encountered, our subconscious controls the duration of cue-triggered cravings.
The importance of the distinction is the recovery confidence provided in knowing that the worst will pass within 3 minutes. But if cue triggered crave episodes peak and begin to subside in less than three minutes, why do the minutes sometimes feel like hours?
Time distortion - A 2003 study found that distortion of time perception is one of the most common nicotine dependency recovery symptoms. Smokers were asked to estimate the passing of 45 seconds both while still smoking nicotine and during a second session after which they had not smoked any nicotine for 24 hours. Their time estimates were also compared to a control group of non-smokers.
While at a loss to explain why, researchers found that time estimation accuracy was significantly impaired (300%) in smokers who had not smoked nicotine for 24 hours, as compared to estimates made while smoking. The ability of smokers who had not smoked for 24 hours to estimate the passing of 45 seconds was also impaired when compared to estimates made by non-smokers. But timing estimates were found to be similar between non-smokers and smokers while smokers were allowed to smoke nicotine.
Keep a watch or clock handy - What the study did not assess was time estimation during occurrence of an anxiety generating crave episode. Whether cessation time distortion is ultimately found to be physiological, psychological or some combination, knowing that it exists allows us to turn to a clock or watch during a crave episode in order to bring honest perspective to time.
When a crave hits, immediately look at your watch or a clock and note the time. The anxiety rush, fear, panic and/or deep seeded belief that the only way it make the crave end is to bring nicotine into your body will soon peak and then pass. Not only will your recovery remain alive and well, at the end of the episode you'll likely receive a reward, the return of yet another aspect of life.
It's important to note that for the 1.7% of adults diagnosed with panic disorder under diagnostic standards such as the American Psychiatric Association's DSM-IV manual, that DSM-IV criteria indicates that panic attacks may not peak for up to 10 minutes. Turn to your training in handling nicotine cessation panic attacks. Hopefully you'll find this aspect of nicotine dependency recovery the easiest of all.
All of us are capable of handling a few brief moments of anxiety, all of us. Being able to accurately determine how long we've endured any challenge will prevent time distortion from making time appear 300% longer than it is. Don't let time distortion deprive you of your dream of again comfortably engaging life as "you."
How often do crave episodes occur?
The best we can do in answering this question is to share study averages. The obvious problem with averages is that we may not be average. A 1998 real-time crave coping study closely followed smokers for two weeks and appears to have collected excellent data. It found that the most crave episodes were encountered was day three with an average of 6.1 craves. Day four's average was 3.5 and by day five it was 3 craves per day. By day ten the average fell to just 1.4 episodes per day.
If each crave episode is less than 3 minutes in duration, and the average on the most challenging day is 6.1, that's a total of 18.3 minutes of crave anxiety on your most challenging day of recovery. Can you handle 18.3 minutes of serious challenge in order to reclaim your life? Absolutely! We all can.
But what if you are not average. What if you have conditioned your subconscious to have twice as many cues as the average user? That would mean that you could experience a maximum of 36.6 minutes of total crave episode anxiety on your most challenging day. Is there any doubt whatsoever that you handle 40 challenging minutes in order to reclaim your mind and life? You won't be asked to do it all at once. Just up to three minutes at a time and then take a break.
We should also prepare you for the possibility of a small spike on day seven. While the average study participant was down to just over 2 episodes per day by day six, day seven brought an average of 4 cravings, before returning to 2 on day eight. We can only guess as to why.
There are lots of theories. One is that life is measured in weeks and a full week of freedom provided the first significant reason for celebration. Was nicotine use part of your celebrations? It was mine. If celebration was one of our conditioned feeding cues we might expect another episode. And what about the celebration that turns sour, like when everyone but mom forgets our birthday? Again, we can only guess. What we do know is that 12 minutes of significant challenge on day seven, followed by 6 minutes on day eight, is entirely doable.
Did you notice how both physical withdrawal and the average number of subconsciously triggered crave episodes peak on day three? Coincidence? Not necessarily. While we have little control over nicotine's half-life, the recovery day on which we choose to fully engage life and confront the bulk of our normal daily subconscious cues is very much within our control.
Joel always started his clinics on a Tuesday night. Historically, many programs have encouraged users to start on the weekend. Although no real evidence, I suspect that most users decide to commence recovery over the weekend, thinking that it will help them avoid work pressures. If so, Monday brings day three, work, more fully engaging life and confronting our normal daily nicotine use conditioning.
Empirical evidence suggests that most subconscious nicotine use cues can be extinguished after a single encounter, during which the conscious mind tells the subconscious mind, "no," "no more."
This does not mean that encountering the same nicotine use reminders day after day won't cause the conscious mind to focus on "thoughts" of wanting. It means that the first encounter, where the subconscious learns that our consciousness will no longer respond to the cue is usually sufficient to break the use association and end the mini-panic-attack type crave episodes that followed.
Recovery is the process of re-learning to engage in every activity we did as users, but without nicotine. As Joel notes, ending all nicotine use almost immediately compels us to confront and extinguish all nicotine-use conditioning related to survival activities such as breathing, eating, sleeping and using the bathroom. Confronting nicotine use conditioning tied our job and getting back to work, performing household chores, or proper personal hygiene can sometimes be delayed, at least briefly.
Joel cautions us that aside from threatening our livelihood and making us look like a slob, if we attempt to hide and avoid confronting use cues associated with non-survival activities for too long, we may begin to feel intimidated that we will never be able to engage in one or more of these activities ever again.
Then there are non-mandatory activities such as partying, dating, nurturing relationships, television, the Internet, sports, hobbies and games. The only way to extinguish use cues associated with an activity is to engage in the activity, confront the cue and reclaim that aspect of life. Again, holding off too long can intimidate us into feeling that we can never do it again. Recovery anxieties caused by delay in reclaiming life are almost totally within our ability to suppress. It is important to quickly reclaim as many aspects of life as possible.
Last night I walked into a convenience store to pay for gas while wearing my "Hug me I quit smoking" tee shirt. The clerk behind the counter asked if it were true. While literally surrounded by cigarette packs, cartons, oral tobacco products and cigars he asked, "Did you really quit?" "Yes," I said. "After thirty years and being up to three packs-a-day."
"I haven't had a cigarette for a week, " he said. You could feel his pride. While heading out the door I heard the lady who had been behind me say, "two packs of Marlboro Lights, please."
Think about his first day on the job after his last nicotine fix. Imagine your livelihood requiring you to repeatedly reach for and handle cigarettes, a conditioned cue for nearly all of us. Yes, the first time may have triggered a cue induced mini anxiety attack. If so, what are the chances he was so busy that it peaked and passed prior to an opportunity to take a break and quiet it by relapse?
While subsequent sales may have caused urges associated with conscious thoughts of wanting, the difference was the absence of an uncontrollable anxiety episode. This time, the intensity and duration of the experience was substantially within his ability to control.
But be careful here. Some conditioned use cues are so similar to others that we fail to grasp their distinction. For example, the Monday through Saturday newspaper may have only been associated with smoking nicotine once, while Sunday's paper is much thicker and may have required replenishment two or more times to read.
Cue exposure therapy - Cue exposure therapy or CET is intentional exposure to drug-related use cues in order to more quickly extinguish learned associations. Although a tool of modern drug treatment programs, it can be our tool too. We can either wait for time and life to bring nicotine use cues to us, or seek out and extinguish use cues as quickly as we desire.
For example, it's likely that nicotine use cues are associated with our daily work schedule or chores. We can fear and delay encountering these use work related use cues or target them for extinction. Our problems in using CET are the same confronting researchers and drug treatment programs.
We can't possibly know all the use cues adopted by the subconscious mind. Even if we did, some situations, such as changing seasons or holidays, would be beyond our ability to reproduce. CET is, at best, only a partial tool. Although we have the ability to boldly and quickly reclaim most aspects of life, we need to accept that some cues will survive and arrive when presented by time or life.
Also, when encountering what appears to be a use cue, how do we distinguish between true 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 nicotine use cues have been extinguished, it is normal and natural for our senses to notice old use situations. The difference is that now we are in full control of our mind's response.
Try to imagine and picture a high quality photograph of your favorite food. It's the best photo of it that you've ever seen. It oozes and drips with flavor. Can you smell it? Imagine that first bite. Savor the flavor and sense the dopamine "aaah" sensation that follows. While I controlled the imagery cues, you controlled the intensity and duration of any desire or urge you may have felt. You were free to stop at any time.
While researchers have discovered that young smokers respond to CET better than long-term smokers, they fail to grasp the obvious. Younger users often have established fewer nicotine use associations and their memories house significantly less dependency baggage.
CET and intentionally trying to meet, greet and extinguish nicotine use conditioning is contrary to historic cessation lessons, the remnants of which can still be found at some Internet sites. For example, the U.S. government's leading cessation booklet is 37 pages and called "Clearing the Air." Page 9 tells readers to stay away from places smoking is allowed, and stay away from people that 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 their favorite chair or watching their favorite TV show. They are 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 television program if taught to fear and avoid it? Sadly, our national quitting booklet is loaded with serious conflicts. 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." Which is it, "meet those triggers head on" or "stay away" from them? Clearly, it wise to stay away from nonsense booklets like "Clearing the Air" as they will only cloud it further.
Let me share one more serious 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.
Back to cue extinguishment. What if we could extinguish some of our conditioned cues without experiencing any cravings? Research suggests that through conscious thought and its subconscious influence that we have the ability to create new expectations conditioning that overpowers old use conditioning, thus allowing a possible avenue by which we can avoid a particular crave episode altogether.
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. Think about the impact upon the subconscious mind of the title to Allen Carr's book, "The Easy Way to Stop Smoking." Don't underestimate the ability of your conscious thinking mind to influence your subconscious. We are what we think.
My most dreaded use cue was walking into the pub after work and having a couple of beers with the guys, as we debated and solved the world's problems. I'd lost my longest cessation attempt ever by combining alcohol with a false belief I could handle "just one." This time, online peer support at Blairsville (QuitSmokingSupport.com), a free message board forum, had taught me about cues triggering craves and I expected a big one. I feared the same result and delayed the after-work gang for three weeks.
I kept thinking how I missed my friends, our discussions, a cold beer, and I wanted it back. Finally, heading into my fourth week, I mustered the courage. Upon opening the door, my healed sense of smell was immediately struck by an overpowering stink. Had it always been this bad? Indirect sunlight highlighted a thin indoor cloud that swirled as the door closed behind me. There they were, thirty or so after-work buddies tackling the day's events.
Scanning the room I was shocked to discover that all of them, without exception, were either smoking a cigarette or had a pack and ashtray within reach. Why hadn't I noticed this before? While only one quarter of American's smoked, I was now discovering that the vast majority of my friends were nicotine addicts. How could this be? Coincidence?
I was prepared to turn and run if needed but it didn't happen. A crave didn't come. After a couple of minutes I grew brave and ordered a beer. It still didn't happen. What was going on? This was my most feared situation of all and yet no craves, zero, none. How could I be standing here, beside smokers puffing away and yet no urge? I'm sure I could have stayed and drank another but I'd been in there for nearly a half hour. I found myself thinking about my still healing lungs every time sunlight pierced the smoke filled room. Increasingly, I felt a slight burning sensation. My lungs didn't deserve this. It was time to leave.
Looking back, it's likely that I'd given so much thought to my biggest fear, while harboring dreams of reclaiming that aspect of my life, that desire somehow severed nicotine use associations. I went back again, a month or so later, with the same result. But I'd punished these lungs long enough and it just didn't seem right.
Our conditioning patterns mirrored how we lived life. We cannot 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. When arrested they were still active nicotine addicts. Imagine their first time driving a car, walking into a bar or running into an old smoking buddy once released. They were hit head-on by conditioned nicotine use cues associated with a host of situations that their arrest and imprisonment had prevented.
As the correct portion of "Clearing the Air" states, "meet those triggers head on." They mark the path home. You may find that there are some aspects of life that you no longer desire but it'll be your choice. By the way, today, nine years later, all but a handful of my closest friends are either comfortable ex-users or never-users.
Confronting alcohol related crave triggers - As mentioned, alcohol use is associated with roughly half of all relapses. It is an exception to the rule that we should try to quickly extinguish learned nicotine use associations.
Regarding alcohol, it's prudent to allow ourselves a few days to get our recovery legs under us and move past peak withdrawal before attempting to use it. Even then, due to diminished inhibitions, the smart move is to consider breaking drinking down into more manageable challenges that present fewer crave triggering cues.
Use associations between alcohol and nicotine can involve multiple cues. We may have nicotine use cues associated with entering a drinking location, sitting down, seeing alcohol containers, hearing ice cubes hit a glass or the sound of a bottle or can opening, picking up a drink, tasting that first swallow or beginning to sense the onset of alcohol's inhibition diminishing effects.
We may have developed nicotine-alcohol use associations where the use cue is encountering a drinking acquaintance, friend or another nicotine user, being around lots of other users, seeing ashtrays, cigarette packs and lighters within easy reach, seeing a cigarette machine or visible packs or cartons for sale behind the bar, or even sight of a jug filled with free matches. Use cues could be associated with engaging in conversation while drinking or having conversation shift gears into debate or argument after alcohol's inhibition diminishing effects begin to be felt.
Impaired judgment and diminished inhibitions may have established nicotine use cues associated with hearing music, feeling the beat, singing karaoke, dancing, flirting, fear, rejection, acceptance, partying, joy, sadness or beginning to feel drunk and turning to nicotine to stimulate the body's nervous system.
So how do we tackle alcohol-nicotine use associations? Consider the benefit of learning to use alcohol and extinguishing our primary alcohol-nicotine use associations in the safest environment available (usually our home), away from other potential use associations. Can you handle nicotine-free alcohol consumption when unaccompanied by other possible nicotine-alcohol use cues? If not, you may be facing alcohol dependency concerns as well. If so, the situation isn't hopeless. Although entirely possible to arrest either dependency alone, research suggests that there is benefit in arresting co-dependencies at the same time (see Chapter 6).
Once able to drink alcohol without using nicotine it's time to extinguish other nicotine-alcohol use associations. Consider not using any alcohol during your first encounter with other potential alcohol-nicotine use situations, or limit alcohol use so as to allow yourself greater conscious and rational control. Drink a bit slower than normal, space drinks further apart or drink water or juice between alcoholic drinks.
Combine your intelligence with baby steps. Have an escape plan and a backup plan and be prepared to deploy both. Since half of all fatal vehicle collisions involve alcohol use, if you do drink, make sure that driving a vehicle is not part of the plan.
The Bigger the Better
Although the above crave episode chart reflects averages of quitter data from a specific study of a unique population, it shows two factors common to every recovery. It evidences the fact that the number of daily crave episodes quickly peaks. It also shows that the number then begins to gradually decline. I'd like to spend a moment focusing upon natural consequences associated with the decline.
Unless following the bum advice portion of "Clearing the Air" and hiding in a closet in order to avoid temptation, locked up in prison, or laid up in a hospital room, we have no choice but to meet and extinguish the bulk of our subconscious feeding cues within the first week. The number and frequency of early challenges kept us on our toes and prepared to swing into action and confront challenge on a moment's notice.
The above graph shows that by the 10th day the average ex-user was experiencing just 1.4 crave episodes per day. That translates to less than five minutes of significant challenge. But what about the days that follow? What would be the natural and expected consequences of beginning to go entire days without once encountering an un-reconditioned crave trigger? What will happen to anticipation, your preparedness, your defenses and battle plans once you experience a day or two without serious challenge?
For purposes of discussion only, let's pretend that during recovery days 14, 15 and 16 that although you remained occupied in dealing with what at times seemed like a steady stream of conscious thoughts about "wanting" to use nicotine, that you did not encounter any un-extinguished feeding cues. Although unlikely you'd have noticed, wouldn't it be normal to begin to relax a bit and slowly lower your defenses and guard?
And then it happens. Assume that on day 17 you encounter a subconscious crave triggering cue that wasn't part of normal daily life. It catches you totally unprepared, off-guard and surprised. You scramble to muster your defenses but it's as if you can't find them, that they too are being swallowed by a fast moving tsunami of rising anxieties. You feel as if you've been sucker-punched hard by the most intense crave ever. It feels endless. Your conscious thinking mind tells you that things are getting worse, not better. The thought of throwing in the towel and giving-up suddenly begins sloshing through a horrified mind.
It is then, when things seem worst, that we need to briefly pause and reflect upon what we're really seeing. Things are not getting worse, but better. Think about how long it's been since your last significant challenge and how relaxed you'd allowed yourself to become. It's likely that this episode is no more intense than prior ones. It's just that you'd taken off your life jacket and you couldn't quickly locate it and put it on. You panicked.
If such an event should happen to you, I encourage you to stop, reflect and then celebrate. You've reclaimed so many once conditioned aspects of a nicotine dependent life that serious challenges are beginning to grow rare. Oh you'll still encounter remote or even seasonal triggers but with the passing of time they'll grow further apart, shorter in duration and generally less intense.
Remember to keep a clock handy so as to defend against time distortion. None of us will ever be stronger than nicotine but then we don't need to be as it's simply a chemical with an IQ of zero. Trust your dreams to your vastly superior intelligence, your greatest weapon of all.
Still just one guiding principle, a principle that no matter how far we travel or how deep our comfort becomes will always remain our common bond ... no nicotine today.
Try to reverse your mind-set. Recovery is about rewards not punishment. Your chemically enslaved survival instincts teacher, your limbic mind with its dopamine "aaah"s and insula driven anxieties, was fooled. It did its job. Now it's time for a mind schooled in nicotine dependency and recovery to save the day and arrest an established dependency.
Extinguishing each conditioned nicotine use cue rewards us with the return of another aspect of life. Why fear being able to finish work, a meal, exit a store or drive without experiencing an urge or crave commanding nicotine replenishment? When a crave hits, try to reflect upon the prize at the end, another slice of life about to be freed.
Crave episodes reflect both evidence of where we've been and the aspect of life now being reclaimed. Moments of subconscious healing are good not bad. Soon, you will have reclaimed so many aspects of life that, like putting together a puzzle, it will reflect a life reclaimed.
Crave Coping Techniques
How do we successfully navigate a less than three minute crave episode? We've already discussed a few. Let's take a look at a few additional coping techniques.
Embracing crave episodes - Upon sensing danger, our survival instincts tell us to either prepare to stand and fight or get ready to run. What approach will you use? Will you duck and run or turn and fight? While the objective is clear - to not use nicotine - our natural instincts on how best to achieve that objective may not be the easiest path to travel.
Can we hide from craving or will they find us? Can we runaway from them or will they catch us? It's the same with going toe to toe in battle, isn't it? Can we beat-up our craves and make them surrender or cry "uncle"? Can we scare them away? I think not. Encountering our use cues and extinguishing each crave trigger is true healing, how we destroy use expectations and reclaim life.
While tobacco's deadly cargo is clearly a killer, what about craves? Can a crave that lasts a couple of minutes kill you? Will it cut you, make you bleed or send you to the emergency room? Can it physically harm you? If it cannot harm us then why fear it?
How much of the anxiety associated with recovery is self-induced? Why agonize over the anticipated arrival of that next crave? Once it does arrive, why u immediately begin feeding your mind additional anxieties that only fuel the fire?
Let's not kid ourselves. The anxiety associated with a craving for nicotine is as real as our arms and hands. While capable of mentally embracing and wrapping our arms around the energy associated with anxiety, most have never done so. Instead, what we feel is a tremendously inflated experience driven by fear, fueled by anticipation, and possibly tense due to a history of prior relapse.
Try this just once. Instead of listening to run, hide or fight instincts, stop, be brave, drop your guard, take slow deep deliberate breaths and in your mind reach out and wrap your arms around the crave's energy. It won't injure or hurt you. It's normal to be afraid but try to be brave for just one moment. Wrap yourself around and feel the true level of the anxiety of healing. Continue taking slow deep breaths as you clear your mind of all chatter, worries, fears and thoughts so that you can sense and appreciate the episode's level of raw anxiety.
Touch it, sense it, hug it hard. Doing so will not make it any more intense than it otherwise would have been. You're witnessing a moment of the most profound healing your mind may ever know. Yes, there is anxiety. But possibly for the very first time, it is not being fed and fueled by you. Now feel as the crave episode's energy slowly begins to subside. You've won. You've taken back another piece of life and did so with hugs not dread.
You will have learned that the greatest challenge presented by natural recovery cannot hurt you. Only we can do that. Embrace recovery don't fear it. There's a special person waiting down the road. Your birthright, it's a person you will once again come to know and enjoy.
Distraction coping - Another means of navigating challenge is to engage in a mental exercise or physical activity which occupies the conscious mind long enough to allow challenge to pass.
Alphabet or counting association schemes demand some degree of focus and concentration and provide an instant means of occupying the mind. An alphabet association scheme can be as simple as going through the alphabet while trying to associate each letter with person, place, animal or food.
Take food for example. The letter "A" is for grandma's hot apple pie. "B" is for a nice crispy piece of warm bacon. "C" is for a rich and moist chocolate cake. I doubt you'll ever arrive at the challenging letter "Q" before three minutes have passed and challenge subsides.
Physical distraction possibilities include turning to your favorite non-nicotine activity, a brief period of physical exercise or something as simple as brushing your teeth. Activities such as screaming into a pillow, squeezing a tree or biting your lip are available should you feel a need to vent. The pillow won't scream back, I doubt you'll hurt the tree and lips heal.
Relaxation coping -. Embracing crave episodes is one means of increasing relaxation by preventing adding of self-induced anxieties. Meditation is another tool for navigating a cue induced crave episode.
Most forms of meditation use breathing and focus to attempt to foster inner peace and tranquility. Research confirms their ability to calm anxieties.
Comfortably sit in a chair or on the floor. Straighten yet relax your spine. Near the level of your naval, lay one hand in the palm of the other with thumbs slightly touching. Gently close your eyes. Now allow your breathing to slow and deepen. Calm and settle your mind by focusing exclusively upon the feelings and sensations of breathing. Focus entirely upon that next breath. Feel the cool air entering your nostrils and its warmth as you slowly exhale. When a thought arises don't chase it but instead breathe it away. Continue focusing upon each breath. As challenge subsides, allow yourself to become increasingly aware of your surroundings as you slowly open your eyes.
Instead of focusing upon breathing, other forms of meditation, panic attack coping and mindfulness based stress reduction encourage exclusive focus upon your favorite color, person or that "special place."
We also should mention laughter. Research shows that laughter activates various muscle groups for a few seconds each, which immediately after the laugh leads to general muscle relaxation, which can last up to 45 minutes. Laughter also induces sporadic deep breathing. There's also evidence suggesting that among those with a sense of humor, that laughter and smiling may result in diminished anxiety and stress.
Remember, this is conditioning that you yourself created, conditioning now commanding you to bring nicotine into your body and relapse. Give laughter's potential calming effects a try. What do you have to lose?
Analytical coping - Here, moments of challenge are spent focusing upon and analyzing the situation. Embracing a crave episode fits nicely here. So does pulling out and reviewing your list of reasons for commencing recovery. Why not put them to work in keeping your motivational batteries fully charged.
What cue triggered the episode? While we can't know for certain, what's your best guess? What activity, emotion, person, place or time might you be rewarded with once this craving is over? Look at a clock at time the episode. How long did it take before anxieties peaked? Is that shorter or longer than your last challenge?
Consider keeping a crave episode log. They make interesting reading. Like medical records, they allow us to quickly look back and see how far we've come. This can be invaluable once our focus is able to intensify upon the final stage of recovery - conscious recovery - as the pace of noticeable change naturally seems to slow.
Oral coping - Oral coping is a form of crutch substitution. It is capable of fostering use conditioning which causes continuing use of the crutch long after challenge has ended. Using food use as an oral crutch may add extra pounds.
We discourage oral coping, especially handling of any object that imitates your nicotine delivery device. Imitating dependency related behavior is contrary to "coping" as it actually invites nicotine use fixation and relapse.
If you find yourself reaching for more than a toothpick or toothbrush, make sure it isn't fattening and something you'd feel comfortable doing anywhere for years to come. For some reason, I fell in love with cold water but not just during challenge, throughout the day.
If you do reach for food, consider eating healthy. Can you eat an entire apple in 3 minutes? If so, according to the FDA, that's 80 calories and 4 grams of fiber. Five asparagus spears are 20 calories, one medium stalk of broccoli is 50 calories, a seven inch carrot that's 1 1/4 inch in diameter is 40 calories, one-sixth of a medium head of cauliflower is 25 calories, two medium stalks of celery total 25 calories, a medium cucumber is 45 calories, a medium orange is 80 calories, one medium peach is 40 calories, seven radishes total 20 calories, eight medium strawberries are 70 calories, and one medium tomato is 35 calories.
Seasonal, Holiday and Infrequent Cues
Expect to arrive home with a few seasonal, holiday and infrequent cues having not yet been encountered. But take heart, an occasional reminder of the amazing journey you've made can discourage complacency from taking root. Infrequent cues can be associated with a vacation, wedding, death, funeral, meeting an old friend or even illness.
"When people catch colds or a flu for the first time after quitting, every other time they had colds or flu during their adult years they were smokers," writes Joel. "Their rate of smoking was likely affected by these infections. When illness symptoms were peaking, meaning when their throats were really raw and their breathing difficult, they likely cut back their amount of smoking to a bare minimum. They were likely experiencing increases in withdrawal symptoms whenever they had such infections. When the cold or flu symptoms finally started to dissipate, they likely increased their consumption quickly in an effort to get their nicotine levels where they needed to be to stave off withdrawal."
"This phenomena could easily result in a person getting increased thoughts for cigarettes the first time they get an infection after quitting," writes Joel. It may not be so much so when they first get sick, but more likely when they first start to get well after being sick. The change in status from feeling ill to feeling normal is a new trigger circumstance for the person. Keep in mind, it is only new the first time a person goes though this kind of change of physical status," he reminds us. "Not smoking will become a habit for a sick or recovering person."
During your second nicotine-free lap around the sun, with a few exceptions, nearly all nicotine use cues will have been extinguished. Oh, you'll still have conscious thoughts now and then but even they are becoming shorter, less intense and further apart. Soon most become laughable. Again, don't fret over them. Let them remind you of how far you came.
Lots of words but just one rule ... no nicotine today.
Exerpts from a free pdf book by Polito JR entitled
"Freedom from Nicotine - The Journey Home"
Copyright 2008 John R. Polito
"Freedom from Nicotine - The Journey Home"
Copyright 2008 John R. Polito
[font=&][/font][font=&] Bargh JA, et al,[/font] [font=&] The Unconscious Mind[/font][font=&], Perspectives on Psychological Science, January 2008, Volume 3(1), Pages 73-79.
[/font][font=&] Galdi S, et al,[/font] [font=&] Automatic mental associations predict future choices of undecided decision-makers[/font][font=&], Science, August 22, 2008, Volume 321(5892), Pages 1100-1102.
[/font][font=&] Wegner DM,[/font] [font=&] Précis of the illusion of conscious will[/font][font=&], Behavioral Brain Science, October 2004, Volume 27(5), Pages 649-659; as reviewed in Bargh JA, et al,[/font] [font=&] The Unconscious Mind[/font][font=&], Perspectives on Psychological Science, January 2008, Volume 3(1), Pages 73-79.[/font] [font=&] Bargh JA, et al,[/font] [font=&] The automated will: Unconscious activation and pursuit of behavioral goals[/font][font=&], Journal of Personality and Social Psychology, December 2001. Volume 81, Pages 1004-1027.
[/font][font=&] operant conditioning[/font][font=&]. (n.d.). The American Heritage® Stedman's Medical Dictionary. Retrieved August 31, 2008, from Dictionary.com website.
[/font][font=&] Rose JE, et al,[/font] [font=&] Inter-relationships between conditioned and primary reinforcement in the maintenance of cigarette smoking[/font][font=&], British Journal of Addiction, May 1991, Volume 86(5), Pages 605-609.
[/font][font=&] classical conditioning[/font][font=&]. (n.d.). Merriam-Webster's Medical Dictionary. Retrieved August 31, 2008, from Dictionary.com website.[/font] [font=&] Lazev AB, et al,[/font] [font=&] Classical conditions of environmental cues to cigarette smoking[/font][font=&], Experimental and Clinical[/font] [font=&] Psychopharmacology, February 1999, Volume 7(1), Pages 56-63.
[/font][font=&] Chae Y, et al,[/font] [font=&] Subjective and autonomic responses to smoking-related visual cues[/font][font=&], The Journal of Physiological Sciences, April 2008, Volume 58(2), Pages 139-145.
[/font][font=&] Franklin TR,[/font] [font=&] Limbic activation to cigarette smoking cues independent of nicotine withdrawal: a perfusion fMRI study[/font][font=&], Neuropsychopharmacology, November 2007, Volume 32(11), Pages 2301-2309.
[/font][font=&] Small DM, et al,[/font] [font=&] The posterior cingulate and medial prefrontal cortex mediate the anticipatory allocation of spatial attention[/font][font=&], NeuroImage, March 2003, Volume 18(3), Pages 633-641.[/font][font=&]
[/font] [font=&] Naqvi, NH, et al,[/font] [font=&] Damage to Insula Disrupts Addiction to Cigarette Smoking[/font][font=&], Science, January 2007, Vol. 315 (5811), Pages 531-534
[/font] [font=&] Zilberman ML, et al,[/font] [font=&] The impact of gender, depression, and personality on craving[/font][font=&], The Journal of Addictive Diseases, 2007, Volume 26(1), Pages 79-84.
[/font][font=&] Sobrian SK, et al,[/font] [font=&] Prenatal cocaine and/or nicotine exposure produces depression and anxiety in aging rats[/font][font=&], Progress in Neuropsychopharmacology & Biological Psychiatry, May 2003, Volume 27(3), Pages 501-518.
[/font][font=&] Tiggemann M, et al,[/font] [font=&] The phenomenology of food cravings: the role of mental imagery[/font][font=&], Appetite, December 2005, Volume 45(3), Pages 305-313.
[/font][font=&] Field M, et al,[/font] [font=&] Smoking expectancy mediates the conditioned responses to arbitrary smoking cues[/font][font=&], Behavioural Pharmacology, June 2001, Volume 12(3), Pages 183-194.
[/font][font=&] Dols M, et al,[/font] [font=&] Smokers can learn to influence their urge to smoke[/font][font=&], Addictive Behavior, Jan-Feb 2000, Volume 25(1), Pages 103-108.
[/font][font=&] Anbar RD,[/font] [font=&] Subconscious guided therapy with hypnosis, American Journal of Clinical Hypnosis[/font][font=&], April 2006, Volume 50(4), Pages 323-334.[/font] [font=&]
[/font][font=&] Niaura R, et al,[/font] [font=&] Individual differences in cue reactivity among smokers trying to quit: effects of gender and cue type[/font][font=&], Addictive Behavior. Addictive Behaviors, March-April 1998, Volume 23(2), Pages 209-224.
[/font][font=&] Klein LC,[/font] [font=&] Smoking Abstinence Impairs Time Estimation Accuracy in Cigarette Smokers[/font][font=&], Psychopharmacology Bulletin, May 2003, Volume 37(1), Pages 90-95.
[/font][font=&] American Psychiatric Association, Panic Disorder, Diagnostic and statistical manual of mental disorders, fourth edition, 1994[/font]
[font=&] O'Connell KA, et al,[/font] [font=&] Coping in real time: using Ecological Momentary Assessment techniques to assess coping with the urge to smoke[/font][font=&], Research in Nursing and Health, December 1998, Volume 21(6), Pages 487-497.
[/font][font=&] Spitzer, J.,[/font] [font=&] Alcohol and Quitting[/font][font=&], Freedom from Tobacco, Message #77176, June 9, 2001.
[/font][font=&] Lee J,[/font] [font=&] Nicotine craving and cue exposure therapy by using virtual environments[/font][font=&], Cyberpsychology & Behavior, December 2004, Volume 7(6), Pages 705-13.
[/font][font=&] Traylor AC, et al,[/font] [font=&] Assessing craving in young adult smokers using virtual reality[/font][font=&], The American Journal on Addictions, Sep-Oct 2008, Volume 17(5), Pages 436-440.
[/font][font=&] National Institutes of Health,[/font] [font=&] Clearing the Air[/font][font=&], April 2003, NIH Publication No. 03-1647.
[/font][font=&] Dols M, et al,[/font] [font=&] Smokers can learn to influence their urge to smoke[/font][font=&], Addictive Behavior, Jan-Feb 2000, Volume 25(1), Pages 103-108.
[/font][font=&] Tuthill RW et al, "[/font][font=&]Does involuntary cigarette smoking abstinence among inmates during correctional incarceration result in continued abstinence post release?[/font][font=&]" (poster). 26th National Conference on Correctional Health Care, Nashville, Tennessee, October 21, 2002.
[/font][font=&][/font][font=&] [/font] [font=&] Agency for Healthcare Research and Quality,[/font] [font=&] Meditation Practices for Health: State of the Research, Evidence Report/Technology Assessment Number 155,[/font] [font=&] AHRQ Publication No. 07-E010, June 2007
[/font][font=&][/font][font=&] Paskind J, Effects of laughter on muscle tone, Archives of Neurology & Psychiatry, 1932, Volume 28, Pages 623-628; as cited in Bennett MP, et al,[/font] [font=&] Humor and Laughter May Influence Health: III. Laughter and Health Outcomes[/font][font=&], Evidence-Based Complementary and Alternative Medicine, March 2008, Volume 5(1), Pages 37-40.
[/font] [font=&][/font][font=&] Fry W, The respiratory components of mirthful laughter, Journal of Biological Psychology, 1977, Volume 19, Pages 39-50; as cited in Bennett MP, et al,[/font] [font=&] Humor and Laughter May Influence Health: III. Laughter and Health Outcomes[/font][font=&], Evidence-Based Complementary and Alternative Medicine, March 2008, Volume 5(1), Pages 37-40.
[/font] [font=&][/font][font=&] Yovetich NA, et al,[/font] [font=&] Benefits of humor in reduction of threat-induced anxiety[/font][font=&], Psychological Reports, February 1990, Volume 66(1), Pages 51-58.[/font]