A Single-Case Experimental Design to Study the Combination of Cognitive-Behavioral Therapy and Pharmacotherapy for Smoking Cessation

Introduction A report by the World Health Organization (WHO) indicates that smoking is a risk factor for six of every eight deaths worldwide. Tobacco use is a risk factor for many chronic diseases such as cancer, pulmonary diseases, and cardiovascular diseases, and is one of the greatest preventable causes of premature death worldwide. However, in general, it has been shown that smoking is an ineffective coping strategy which causes undesirable outcomes. Medications such as nicotine replacement therapy (NRT), varenicline, bupropion, cytosine, and behavioral support increase the success rate of smoking cessation (1). Bupropion (Wellbutrin and Zyban) is a category of aminoketones and is an anti-depressant drug that is effective in smoking cessation (2). On the other hand, studies have shown that bupropion along with cognitivebehavioral therapy is effective in treating smoking (3). Previous studies have shown that the combination of pharmacotherapy and behavioral interventions increases the likelihood of success in smoking cessation (1). The results of the meta-analysis by Stead et al (4) indicated the effectiveness of the combination of pharmacotherapy and behavioral support. On the other hand, nicotine dependency and depression have high comorbidity. A possible mechanism is that nicotine reduces neurobiological disorders associated with depression. For example, the activity of corticostriatal circuitry is intensified by nicotine, while this pathway is impaired in people with depression (5). Studies have shown that avoiding tobacco use reduces the response to non-pharmacological therapies or anhedonia (6). Anhedonia is a tobacco withdrawal syndrome after smoking cessation. The experience of anhedonia is known to be a factor in starting to consume and continue smoking in adults (7). Considering the therapeutic Abstract Bupropion is an anti-depressant drug which is a category of aminoketones. It is a norepinephrine-dopamine inhibitor, which is considered as a nicotine antagonist and is effective in smoking cessation. The patient was a single 21-year-old girl and she was a student and had been referred to Bijan Addiction Treatment Clinic in Tehran with a complaint of chronic smoking. After a period of abstinence from consumption, she experienced anhedonia syndrome and recurrence of consumption. Data were collected from October to February 2016. We used a reversal (ABAB) design with multiple baselines, in which A was the baseline and B was the intervention phase. The entire course was 12 weeks, during which bupropion was presented. In the baseline A1 and A2, only bupropion was presented, and in B1 and B2 stages, in addition to bupropion, cognitive-behavioral therapy (CBT) was also presented. Cigarette Cravings Index and Heaviness of Smoking Index (HSI) were completed at 24 time points by the subjects. Data were analyzed by semi-parametric test of generalized estimation equation. Data analysis indicated that the addition of CBT to bupropion was associated with a significant reduction in the scores of HSI and Cigarette Cravings Index compared to bupropion alone (P<0.01). These findings can reflect the role of complementary psychological interventions in the treatment of addiction and suggest a promising perspective in linking biological and cognitive indices in response to the addiction challenge.