Components of effective intervention

Components of effective intervention – Smoking Cessation, part 2

Janice Y. Tsoh

Smoking cessation treatment is an essential component of comprehensive

healthcare, but many healthcare providers lack formal training and are

hesitant to provide such intervention. The recently published US Agency for

Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice

Guideline provided empirically based recommendations to address these

issues. The most effective components of smoking cessation include the use of

nicotine replacement therapy, provider support and encouragement, and

training in such skills as problem solving and coping. Methods of using

these recommendations are illustrated, and sample scripts are offered to

serve as references for providers from various disciplines who conduct

smoking cessation interventions.

Index Terms: behavioral treatment, disease prevention, interventions,

nicotine replacement therapy, smoking cessation, tobacco

Smoking cessation is a cornerstone for disease prevention and health promotion.[1] However, fewer than 60% of the smokers surveyed in a report published in 1995 said they had ever received explicit instructions on how to quit.[2] Many practitioners may not engage in smoking cessation treatment because they have not been trained in these skills.[1,3,4] The recently published US Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline[1] was designed to provide empirically based recommendations for clinicians in various disciplines (see Table 1).

TABLE 1

Recommendations of the Smoking Cessation Clinical Practice Guideline

[check] Smoking cessation treatment should be offered to ALL smokers at EVERY office visit.

[check] Clinicians should ask and record tobacco use status of every patient.

[check] Smoking cessation treatment as brief as 3 minutes is effective.

[check] The more intense the treatment, the more effective it is in producing long-term abstinence from tobacco.

[check] Nicotine replacement therapy (NRT) combined with social support and skills training delivered by clinicians is the most effective combination of treatments.

[check] Healthcare systems should be modified to identify and intervene routinely with all tobacco users at every visit.

In this article, we illustrate the use of these recommendations in clinical practice. We hope that the article will serve as a reference for providers who have opportunities to intervene with smokers, regardless of their role in delivering smoking cessation intervention. The sample scripts we provide illustrate intervention techniques that are based on recommendations by the AHCPR Guideline,[1] other recent research, and our own clinical experiences.

According to the AHCPR’s expert panel, the most effective smoking cessation treatments involve a combination of three major components: nicotine replacement therapy (NRT, patch or gum), clinicians’ support, and skills training. The Guideline[1] also recommends involving a variety of clinical specialists in delivering smoking cessation interventions (eg, physicians, dentists, nurses, pharmacists, psychologists). In the following pages, we discuss each component separately, and in the last section we focus on bringing these major components together in a comprehensive smoking cessation program.

Use of Nicotine Replacement Therapy (NRT)

NRT is a common adjuvant to smoking cessation treatment. The Guideline[1] recommends use of NRT in the forms of transdermal nicotine patches or nicotine gum, both of which are available to consumers over the counter. At 6 months post cessation, the abstinence rates of persons using nicotine patches were at least two times greater than the rates of patients given placebos (patch, 22% success v placebo, 9%).[5] Similarly, the use of nicotine gum produced a 40% to 60% increase in abstinence rates at 12-month follow-up when compared with placebo (gum, 16.9% to 18.2% v placebo, 10.6% to 12.8%).[6-8]

The Guideline recommends using the nicotine patch for routine clinical practice. Although research has shown similar efficacy for both the patch and gum, this recommendation is based on findings of fewer compliance problems and the ease of use of the patch. Combined use of the nicotine patch and gum seem intuitively appealing, but there is little evidence to date suggesting that combined use (compared with using either of the NRTs alone) increases abstinence beyond 24 weeks.[9,10]

The use of NRT is relatively safe, however it is not recommended for all smokers. In particular, nicotine replacement may be contraindicated for individuals with cardiovascular disease (eg, severe arrhythmia, severe or worsening angina pectoris, or a myocardial infarction within the past 4 weeks) or active peptic ulcers.

Although the federal Food and Drug Administration (FDA) has approved the use of both patch and gum with pregnant smokers, the FDA has stipulated that NRT should be used only when the benefits of its use clearly outweigh the risks incurred by the fetus.[11] Unfortunately, we know of no clear guidelines for making this decision. Thus, pregnant smokers should first be encouraged to quit without pharmacological intervention. Similar precautions should be exercised for nursing mothers.

Finally, using the nicotine patch may be contraindicated for individuals with skin allergies or dermatologic diseases. Similarly, the gum should be used with caution in individuals with jaw problems.

Instructing Patients in the Use of NRT

To increase patients’ compliance with NRT therapy, providers should present a clear rationale for use and realistic expectations about the response. From our experience, one of the most common areas of noncompliance is premature discontinuation of NRT. In the following script, the provider outlines the rationale for how the patch works:

One reason people smoke is to obtain nicotine. Nicotine is

the ingredient in tobacco smoke believed to be responsible

for addiction or tobacco dependence. Many smokers feel bad

when they stop smoking. They may experience cravings for

cigarettes, tension, irritability, sadness, problems with sleep,

and difficulty concentrating. These symptoms are partly the

result of nicotine withdrawal–the reaction of our bodies to

the removal of nicotine when we are accustomed to getting it.

Sometimes, people want a cigarette in specific situations

where they are used to smoking, such as after a meal or while

driving. Problems with withdrawal and a desire to smoke in

particular settings may lead to relapse. The patch can help by

maintaining a constant (but lower than smoking) level of

nicotine throughout the day. Using the patch results in less

desire to smoke and provides an opportunity for a new nonsmoker

to practice all of the new nonsmoking skills without

being burdened by cravings.

Refer to Figure 1. Here is a graph of nicotine levels in the

bloodstream over the course of a day when a person is allowed

to smoke as he or she normally would. Notice the

peaks and valleys in the nicotine blood levels and how quickly

the blood level of nicotine is boosted after each cigarette.

It takes 7 seconds for a smoker’s nicotine to travel to the

brain.[12] See how the nicotine levels in the bloodstream fall

off rapidly when a person has not smoked for a while (at

night, for example).

Refer to Figure 2. Here is a graph of nicotine levels in the

bloodstream when an individual uses the patch. Notice the

steady gradual rise in blood nicotine that levels off and remains

constant for much of the day, then gradually decreases

while the person is asleep. The low levels (valleys) of nicotine

in the bloodstream are associated with withdrawal symptoms.

An individual who quits smoking and uses the patch no

longer experiences the peaks (high levels of nicotine) or the

valleys (low levels of nicotine) because nicotine previously

obtained from smoking is replaced by nicotine from the

patch. Therefore, withdrawal symptoms are lessened by

maintaining an adequate blood level of nicotine. However,

you may still experience cravings as a result of your body’s

“call” for those “peaks” of nicotine experience.

A similar rationale can be used if patients are using gum. It should be emphasized that NRT is not a “magic bullet” and that the use of coping skills is essential for abstinence. The patch or the gum only buys time by reducing withdrawal symptoms and giving individuals a chance to figure out alternatives that they can use in place of smoking in many different situations.

Even though the use of the patch or the gum seems relatively simple, it is helpful to give a full explanation of the proper use of NRTs and provide patients with an instruction sheet for reference (see Tables 2 and 3). Misunderstanding the instructions is a common problem that can compromise the effect of NRT interventions.

TABLE 2

Instructions for Use of the Nicotine Patch

NO SMOKING while on the patch.

Apply the patch as early as possible on quit date (immediately upon waking).

Wear each patch for 24 hours, including while asleep (unless otherwise directed).

Use a new patch every 24 hours and discard the old one.

Avoid applying a new patch before bedtime.

Apply patch to nonsensitive, nonhairy (shaving may be necessary), dry, and clean area.

Recommended patch sites are below the neck and above the waist.

Rotate sites of patch application each day.

TABLE 3

Instructions for Use of Nicotine Gum

NO SMOKING while using the gum.

“Chew and park”–gum should be chewed until a “peppery” taste emerges, then “park” nicotine gum between cheek and gum to facilitate nicotine absorption. This should be repeated occasionally for about 30 minutes.

Avoid drinking, especially any acidic beverages such as coffee, juices, and soft drinks, except for water. Avoid eating 15 minutes before and after chewing.

Use at least 1 or 2 pieces each hour; do not exceed 30 pieces/day.

For example, patients may misinterpret the instruction not to smoke while wearing the patch as “take off the patch when you smoke.” Patients should therefore be told not to remove the patch in response to an urge to smoke. They need to keep the patch on at all times and not smoke, because smoking while wearing the patch defeats the purpose. Only if patients continue to smoke or decide they no longer desire to quit smoking should the patch be removed. For those who report severe cravings in the morning, despite use of the patch, providers may consider instructing the patients to put on a new patch 2 to 3 hours before the time they usually wake up and start their day.

Other Clinical Concerns With the Use of NRT

Side effects of NRT. Both the patch and gum have relatively few side effects. Nausea and lightheadedness are possible signs of nicotine overdose that warrant a reduction of the dose of the NRT agent used.

The most frequent side effect with the patch is skin irritation related to the adhesive or the medium containing nicotine, but not to the nicotine itself. About 50% of the patients reported skin irritations during the course of treatment.[1] Rotation of the patch site usually alleviates this. The use of over-the-counter hydrocortisone cream (5%) or triamcinolone cream (0.5%) is recommended as a local treatment for patch-related skin irritations. If appropriate, providers may consider switching to a different brand of patch because patients may be allergic to the adhesive, the nicotine medium of a particular brand of patch, or to both. Providers may also consider switching to nicotine gum if the patient reports severe skin reactions.

About 23% of patients using the patch report sleep disturbances.[13] Insomnia is a common withdrawal symptom, especially during the first few weeks of quitting. Depending upon the extent to which the patient’s daily functions are interrupted, a wait-and-see approach is recommended to determine whether the symptom disappears spontaneously. If the symptom is severe and lasts for more than a few weeks, providers may consider instructing the patient to take off the patch at bedtime and have a new patch ready for the next morning.

Duration of NRT. A minimum of 6 to 8 weeks is required for nicotine-patch treatment. No significant increase in treatment efficacy has been found beyond 8 weeks.[5] However, for individuals who continue to experience severe withdrawal symptoms beyond 8 weeks, longer treatment may be warranted.

The use of gum for at least 1 to 3 months is recommended.[1] Studies have found, however, that 15% to 20% of abstainers continue to use the gum for longer than 12 months.[14,15] Maximum effort should be devoted to encourage compliance with the patch and/or the gum regimen for the minimally acceptable duration of treatment.

Dosages and gradual reduction. Various dosages of nicotine patch are available. Generally, the maximum dose (ie, 21 mg/day for Habitrol and Nicoderm, 22 mg/day for Prostep, and 15 mg/day for the Nicotrol 16-hour patch) is recommended for smokers who smoke 10 to 15 cigarettes or more per day. Traditionally, a gradual fading procedure in which the patch dose is stepped down at 2- to 3-week intervals is used. However, no empirical support exists for using this procedure rather than a single maximum dose for approximately 6 weeks.5 From our clinical experience, a gradual reduction seems to make intuitive sense and is generally preferred by patients because each reduction in the dose signifies a milestone in the process of quitting.

Regarding the use of gum, 2 mg should be considered the optimal dose for most patients.[1] Providers may consider using 4-mg gum for those who smoke at least 20 cigarettes a day.[1] No formal, empirically based recommendations are available regarding decreasing gum use. Patients tend to cut down gradually or discontinue the gum after using it for some time because of the gum’s unpleasant taste or other side effects.

Summary of NRT

NRT is an effective adjuvant to smoking cessation treatment and should be used when patients are prepared and ready to quit smoking completely. Providers should educate patients about proper use of the patch or the gum to reinforce compliance and achieve optimal treatment effectiveness. NRT alone is not a cure for smoking. Psychological interventions, skills training, and emotional support are also important during the patient’s quitting process.

Supportive Treatment Components

According to the AHCPR panel’s findings, a second important component of effective smoking cessation is provider support. Research has consistently shown a strong dose-response effect between the intensity of counseling and a positive outcome. Supportive intervention, even as brief as 3 minutes, has been found to be beneficial.[1] Among the 39 studies the AHCPR panel members reviewed, 21 showed that provider support produced an average increase of 80% in cessation rates. Average cessation rates were 15.2% with provider support versus 8.8% with no contact.

Providers may offer support to patients in many ways. An understanding of how individuals change habitual behaviors, such as smoking, is helpful in tailoring intervention strategies according to individuals’ needs during the process of change. The transtheoretical model, a useful conceptual framework for understanding how people change behavior, has been successfully applied to a broad range of problem behaviors.[16-18]

According to the transtheoretical model, as people attempt to quit smoking, they go through a series of stages that include (a) precontemplation (not intending to quit smoking in the next 6 months), (b) contemplation (considering quitting in the next 6 months or in the foreseeable future), (c) preparation (intending to quit in the next 30 days), (d) action (having quit smoking within the last 6 months), and (e) maintenance (having quit for more than 6 months).[19,20] Each stage of change captures specific constellations of attitudes, intentions, and behaviors of individuals going through the process of change.

If patients have no intention of quitting because of their lack of awareness of smoking as a problem, an appropriate intervention would be to provide basic information about smoking and health. Similarly, supportive strategies for patients who have quit smoking for quite some time may include reinforcing the benefits of smoking cessation and praising patients for their success in quitting.

The techniques we have considered thus far and will discuss in the rest of this article primarily target individuals at the preparation, action, and maintenance stages of change. Detailed techniques for each stage of change, including how to motivate those who are not ready to quit smoking, are described elsewhere.[21,22]

The common elements of provider support in smoking cessation treatment identified by the Guideline include encouraging patients in their attempt to stop, communicating caring and concern, encouraging patients’ discussion of the quitting process, as well as providing basic information about smoking and successful quitting experiences.

Encouraging the Patient

Noting that effective cessation treatments are available. It is helpful for clinicians to tell patients that about half of all people who have ever smoked have now quit. Providers may offer hope to their patients by telling them that they are not alone in quitting smoking with such comments as the following:

We have learned that the combination of NRT and counseling

is the most effective way to stop smoking. By decreasing

the withdrawal experience, NRT helps the people practice

new skills that they have learned. The chance of successful

smoking cessation doubles with the use of NRT.

Communicating belief in the patient’s ability to quit. Many patients tend to use “lack of willpower” as the reason for their failures. Research has shown that the use of willpower is ineffective in smoking cessation[23] and that the use of coping skills is essential in determining the success of abstinence.[24] Offering promising treatment components, such as skills training, is helpful in engaging the patient in the quitting process. The following sample script may be used to illustrate this idea:

If I ask you whether or not you have the willpower to drive,

what will you say’? “Of course, what a silly question!” However,

before you learned how to drive, you probably would

have said “no.” Similarly, the fact that you are here and have

expressed your desire to quit smoking indicates you already

have the willpower to quit. What is lacking is the skillpower

that we will train you in during this program.

Providers should also inform patients who have relapsed in the past that previous attempts to quit are going to help because most people succeed after at least three attempts.[25-27] Patients should be encouraged to learn from their previous attempts and reframe those attempts as stepping stones to success. For example, the provider can say,

Later in the program (treatment), we will map out strategies,

based on your previous experience, that will help you conquer

the difficulties you may encounter with quitting. This time is

going to be very different because you are better equipped

with what you have learned in the past; and your previous

experience is going to make you a more matured nonsmoker.

Setting a quit date. Providers can help patients move from an intention to quit smoking into an active plan. They can do this by helping the patients select a quit date, ideally within 2 weeks.[1] Patients may wish to tell important others about their quit date as a way of getting additional support. Setting a quit date also allows providers to work with their patients to tailor a specific action plan.

Communicate Caring and Concern

Understanding. Research findings have indicated that, from patients’ perspectives, physicians who were supportive, caring, and empowering (as opposed to being diagnostic and authoritative) were more effective in delivering smoking cessation treatment.[28] From our clinical experience, we believe that patients especially appreciate a nonjudgmental attitude on the part of counselors. This attitude enables patients to discuss their problems related to smoking freely, especially in the case of relapse. Putting the nonjudgmental approach into practice means honoring and respecting each individual’s preferences and decisions. The following script is an example of communicating this philosophy:

You and I (the provider) are going to be working as a team.

You may see me as your coach and cheerleader. However,

you are the star player of the game. It is the coach’s responsibility

to make the best recommendations, but it is the star

player’s (your) responsibility to choose which suggestions to

use, to modify the suggestions whenever appropriate, and to

put the recommendations into practice.

Patients should be encouraged to discuss concerns and difficulties they encounter while they are quitting, as well as the successes they achieve during the process. Furthermore, patients should be reassured that although perfect performance is not required, open discussion of their feelings and experiences is important.

Openness for patients’ expression of feelings. Patients may feel ambivalent about quitting because of their fear of failure, sadness about giving up smoking, concerns regarding barriers to quitting, and difficulties they anticipate they may encounter during quitting.

The following techniques may be employed to help patients cope with their feelings of ambivalence about quitting. First, directly ask the patients how they feel about quitting or whether they have had any concerns about quitting, prior to and during the course of smoking cessation. Then, communicate to the patients that ambivalent feelings and fears regarding quitting are not uncommon. If patients indicate that they are not interested in discussing their ambivalent feelings about quitting, providers can offer opportunities for the patients to discuss their feelings in the future, should they wish to do so. If the patients are ready to discuss the issues, providers should help them acknowledge and label their feelings. Labeling feelings and concerns involves asking what, how, and why a person is feeling a certain way. After identifying feelings and concerns about smoking cessation, providers should summarize and reframe these feelings; the feelings can then be used as tools to develop further skills during subsequent sessions. Last, skills training should be provided to address the patients’ specific concerns.

Encouraging Patients to Discuss the Quitting Process

Providing a supportive environment may encourage the patient to discuss the quitting process and help the provider tailor the intervention to the patient’s needs. Focal points differ, depending on where the patient is in the course of quitting. Appropriate use of supportive elements at the right moment will further enhance therapeutic effectiveness. For example, soliciting and reviewing personal reasons for quitting and for smoking are important, particularly during the early phase of quitting. It is also helpful to acknowledge (but not emphasize) that smoking is sometimes enjoyable. Thus, although patients are giving up something that they find reinforcing, they need to be assured that they are pursuing even more valuable goals by quitting smoking.

Postcessation concerns, such as weight gain (which we discuss later in this article) and changes in life routines, often bring anxiety. Patients may ask, “What am I going to do with myself without a cigarette?” One approach is to have them consider what nonsmokers do when they are stressed, after meals, and so on, using examples from their friends or family members who do not smoke.

Providing Information About Smoking and Successful Quitting

Education is an important element in intervention. It is not surprising that many smokers know little about the impact of smoking on health or the benefits from quitting. A survey among 225 smokers published in 1995 found that 56% of the smokers failed to identify smoking cessation as a health priority and perceived much less control over their health status than did those smokers who identified smoking cessation as a priority.[29] In the Adult Use of Tobacco National Telephone Survey (AUTS) of more than 9,500 adults, less than one third of the older smokers believed that there is a strong connection between smoking and illness. Older smokers tended to attribute some smoking-related symptoms to the natural aging process.[30]

Addictive nature and consequences of smoking. Smokers are generally aware of the addictive nature of cigarettes. However, they may not be aware that the addictive power of nicotine is as potent as other illicit drugs, such as heroin and cocaine.[31] Consequences of smoking are best presented in the context of the individual’s current health status because having personal concerns about the impact of smoking on one’s health status has been linked to successful cessation.[32] The provider should also emphasize the benefits of quitting, which are well documented in the 1990 surgeon general’s report on smoking cessation.[33]

Nature of withdrawal symptoms. The severity and duration of withdrawal symptoms vary among individuals, but the symptoms are generally very unpleasant and frequently intolerable.[31] Most patients relapse before the symptoms begin to subside.[34,35] The nicotine withdrawal syndrome includes dysphoria, anxiety, insomnia, irritability, increased appetite, and decreased concentration and heart rate.[36]

Onset begins within a few hours of the last cigarette and includes an increased tendency to smoke, impaired cognitive function, and altered electrocortical function.[37,41] Withdrawal symptoms peak within a few days, then begin to subside over the following several weeks. Nicotine replacement reduces symptom severity to a more tolerable level, but it does not appear to shorten the course of the symptoms. Some individual’s withdrawal symptoms, particularly cognitive impairment, cravings, and irritability, may persist for several months or longer.[31,42]

The following sample script illustrates how to provide information about withdrawal symptoms that should be supplemented by coping-skills training:

Remember, many of these symptoms will be gone in a week

or two. In fact, most symptoms will be completely gone within

a month of your last cigarette. Urges to smoke may take a

little longer to go away, but the longer you are abstinent, the

less frequent and less intense they become. Believe it or not,

most urges will pass within 3 to 5 minutes. Furthermore, the

nicotine patch will make the cessation process easier.

Total commitment to abstinence. Patients should be advised that even a puff on a cigarette is unacceptable after they have stopped smoking. Research findings have indicated that 95% of ex-smokers who take only one puff relapse.[43] Furthermore, those individuals committed to total abstinence are less likely to slip and are also less likely to relapse after a slip than those who are not committed to total abstinence from smoking.[44] It is not uncommon for patients to feel strongly that it is important for them to keep a cigarette (as a “security blanket”) or to test themselves in situations that increase the risk of smoking. The following question may help in showing the importance of this advice and the no-testing concept: “How many nonsmokers do you know who keep a pack of cigarettes handy just to test themselves?”

Many patients do not yet see themselves as nonsmokers; they may need to be reminded of their new nonsmoking status. We recommend having patients renew their commitment to abstinence during the course of quitting.

Summary of the Social Support Component of Smoking Cessation

Building rapport and providing a supportive environment are the basis of successful intervention. The supportive elements in counseling interventions may increase patients’ receptivity to the skills that will be taught during the session on social support. These elements, although we discuss them separately from the skills-training techniques, should be used hand-in-hand with skills-training interventions.

Common Elements of Problem Solving and Skills Training

The third important element of successful smoking cessation treatment is skills training.[1] The Guideline[1] indicates that the inclusion of a general problem-solving approach increases cessation rates. Among 39 studies and 57 comparisons included in the panel review of the Guideline, using problem solving and skills training yielded a 60% increase in cessation rates (15.2% of those who were taught the problem-solving approach versus 8.8% of those with no contact). Problem-solving techniques in smoking cessation treatment, as recommended in the Guideline, include recognizing tempting situations for smoking, learning coping skills, stress management, and relapse prevention.

Recognizing Tempting Situations

Recognizing tempting situations involves training the patient to identify events, internal states, or activities that they believe increase their risk of smoking or relapsing. This training should begin before the patient’s quit date. Research findings have shown strong associations between environmental settings and emotional states and lapses.[45,46] The most common situations that lead to lapses include being around those who smoke, in places where cigarettes are available or where smoking is allowed, and drinking alcohol and experiencing negative moods.[46]

The focus of training in problem solving and using appropriate skills is to increase the patient’s awareness of cues to smoke, as well as to empower the patient in dealing with urges, by teaching patients coping strategies. The following sample script illustrates how this training can be conducted

After you stop smoking, temptation will still be around. But

if you see it coming, it is not as likely to get you. Some

tempting situations may be talking on the telephone; finishing

a meal; getting up in the morning; driving; drinking alcohol;

being around other smokers; drinking coffee, tea, or

cola; stressful situations; social occasions; wanting something

to do with your hands; being in pain; wanting to celebrate;

or relaxing.

Throughout the coming week, look for your pattern of

urges each day. When are you tempted most? Who are you

with? What are you doing? How do you feel’? How long does

the urge last? Write down the three most tempting situations

that you encounter and think of the strategies you might use

to fight the urges. Make a plan. Every day, plan how you will

conquer the day’s temptations. Remember, if you see the

temptations coming and plan for them, you are more likely

to be able to conquer the urge to smoke in the tempting situations.

Some patients, especially those who have not slipped or have had a more moderate-to-benign withdrawal experience, may take this training lightly. For example, some of our patients said, “I’ll deal with them as they come.” Helping patients recognize the significance of preparing is important. Providers may consider using the following analogy:

Imagine that one day you are driving your favorite automobile

(use the name of patient’s dream automobile) and pass

through a big pothole. Luckily, you have a sturdy car and it

was not damaged. What would you do if you were to go to

the same destination again?

Most patients readily reply with responses such as “take an alternative route,” “drive slowly,” or “avoid the pothole,” although one patient of ours did say, “It depends on whose car I’m driving ….” The provider’s response may be “Very good!You’d simply drive differently. We are trying to apply the same idea here, which is to learn to identify and anticipate potential “potholes” in your road to cessation so that you can be prepared to “drive” differently.

Coping Strategies

Techniques to fight the urge to smoke are essential in smoking cessation, both for quitting and for staying abstinent. Research findings have demonstrated that individuals who are able to abstain from smoking use significantly more coping strategies than those who fail in the attempt. Both behavioral and cognitive coping strategies are important. However, recent research that used ecological momentary assessment (EMA),[47] a close-to-real-time data collection approach (as opposed to retrospective), found that cognitive coping, such as positive self-talk, outperformed the use of behavioral strategies in preventing temptations from becoming lapses.[46]

The emphasis in the training is to encourage patients to experiment, practice, and adopt as many different coping skills as possible. We have used the acronym ACE to help patients remember potential coping strategies based on three major techniques: Avoid, Cope, and Escape. The following sample script illustrates how this training can be conducted:

Avoid situations that you may not be ready to handle yet,

such as going to a smoke-filled bar. This also includes taking

control of your environment to remove items that will be

tempting to you—cigarettes, ashtrays, lighters–for example.

Cope, using strategies that help you deal successfully with

tempting situations. One good example of a coping technique

is distraction, which can include going for a walk,

exercising, calling a friend, or reading a book–anything that

gets your mind off smoking. Another good coping strategy is

the use of incompatible behaviors, such as chewing gum, eating

a peppermint, snacking on low-calorie foods, drinking

orange juice, or playing with something in your hand. In

other words, any behavior that is not compatible with smoking.

Another very powerful coping strategy is positive self-talk,

which can be used whenever and wherever you are.

Helpful thinking about quitting includes reminding yourself

of the benefits of quitting (eg, more money saved, improved

health, good feelings about success, greater enjoyment of the

taste of food) and using such positive self-statements as

“Don’t worry about tomorrow, next week, or the rest of your

life. Just take it one day at a time”; “Smoking is not an

option, I can do almost anything in the world to cope with

situations and urges, except smoking”; “I am making

progress”; “I can do this, I can pass up a cigarette,” etc.

Escape from circumstances that you cannot avoid and find

that you are not yet ready to handle. For example, you are at

dinner and some people at your table start to smoke; you can

choose to step outside until they have finished their cigarettes.

If you are at a party where people are smoking, you

can hang out with your nonsmoking friends. This way, you

do not limit the activities that you enjoy, but you escape from

specific situations that may be too tempting.

Some patients may not be motivated to consider using the avoidance (stimulus control) strategies, feeling strongly that they might need to put themselves into high-risk situations intentionally so that they can learn to handle them. Unfortunately, this often leads to a relapse. Providers might consider using the following analogy to dissolve this misconception:

When people have surgery, they need plenty of time and rest

before they go back to all their regular activities. Similarly,

the first few weeks after you quit, you must realize that you

are vulnerable and need to recover before going back to

those activities that increase the risk of smoking.

At the beginning, patients may tend to rely on one or two strategies that seem to work well for them. However, when those strategies fail because of circumstances, the patients are caught without other options. For those who may be resistant to adopting various strategies, the following sample script can be considered:

Having more than one or two strategies is very important for

you. What we are trying to do is expand your toolbox, so that

if one tool does not work, you will have another. In many situations,

you may require a combination of various tools.

Some patients may have difficulties in generating alternative strategies to cope with tempting situations. Providers can assist them by helping them recall a recent successful experience in overcoming a particular situation. For example, one common situation is wanting to smoke after a meal. Many patients have resisted this temptation before returning to the treatment visit. Therefore, providers may simply ask the patients what they did and encourage the patients to generate more alternatives by asking the patients “What if that didn’t work?” For patients who have experienced a recent slip, it is effective to help them discuss the situation and identify warning signs, then generate alternative strategies.

Stress Management

Researchers have documented that stress often leads to negative emotions, smoking, and relapsing after quitting. The most common precipitant of smoking relapse has been found to be negative affect.[23,45,46,48,49] Carey and colleagues compared the coping strategies for stress of self-quitters and nonquitters (those who relapsed).[50] They found that quitters reported greater use of effective stress-coping skills and a lower level of perceived stress during the quitting process.

A number of techniques have been evaluated and identified as effective in managing stress.[51,52] When stress-management strategies are applied in the context of a smoking cessation program, providers should help patients understand the “acquired” relationship between stress and smoking. Smokers often associate smoking with relaxation and stress reduction. Helping patients identify potentially stressful situations and generate new methods of coping is necessary. The following is a sample script showing how this training can be introduced:

For many smokers, smoking is a convenient way of handling

all types of stressful situations. For example, you may have

noticed that you often reached for a cigarette when you were

feeling angry, sad, or frustrated. Situations that are accompanied

by negative feelings (eg, being depressed, angry, bored,

or tense) and even those that are associated with positive feelings,

such as parties and celebrations, seem like a good time

to light up.

This reaction is no accident because nicotine affects certain

chemicals in our brains (serotonin, norepinephrine,

dopamine) in a way that may help relieve some of these negative

feelings or increase the positive ones. However, when

you use the strategies and skills we have discussed, you are

doing this in a different way. You now have a long-lasting

method for managing your moods without smoking.

Training should emphasize that smoking is no longer an option for handling stress. Providers may solicit examples from their patients’ personal experiences to illustrate the use of the principles of managing stress without smoking; they will also find it helpful to encourage patients to discuss the ways a cigarette might have served them in previous stressful situations.

Stress-management strategies can be broadly divided into two categories: those that focus on relieving the stress responses (eg, tension, anxiety) and those that focus on problem solving to control the present and future situations. Among the techniques for relieving stress responses are relaxation through deep breathing; visual imagery; progressive muscle relaxation; positive self-talk; and engaging in distracting behaviors, such as doing puzzles and exercising.

Common examples of problem-solving approaches include assertiveness and time-management skills. Cognitive restructuring refers to evaluating and changing beliefs that are irrational and are often a source of stress. This process takes time and calls for helping a patient become aware of his or her irrational beliefs, as well as assisting the patient in adopting a more effective style of thinking.

Relapse Prevention

The problem of relapse in smoking is enormous; The relapse rate is comparable to that found with persons addicted to using cocaine, heroin, and alcohol,[53] The Guideline recommends relapse-prevention interventions for all exsmokers.

Suggested techniques for providers include giving their patients recognition, congratulations, and encouragement, as well as expressing concern for their maintaining abstinence. At the end of the treatment program, providers may consider issuing a certificate to patients in recognition of their efforts in quitting smoking.

The Guideline also recommends engaging in active discussions, reviewing the benefits the patients have experienced from quitting, praising their success in quitting, and discussing any concerns that patients may have after they have stopped smoking. Revisiting and cheering the patients’ successes and benefits adds another layer of positive reinforcement.

Common problems patients encounter in maintaining abstinence include weight gain, negative mood or depression, prolonged withdrawal symptoms, and lack of support for their cessation.[1] The Guideline recommends consideration of appropriate pharmacological management for depression and extension of NRT for prolonged withdrawal symptoms. Follow-up contacts through the telephone are also recommended to provide patients with necessary support. Research findings have indicated that multisession telephone counseling is often effective in reducing relapse rates.[54]

Weight gain is a common problem for people who give up smoking. The authors of the Guideline, on the basis of empirical data, discourage significant interventions that involve dietary restrictions immediately after someone quits smoking. Postcessation weight gain of 5 to 10 pounds is common. Most individuals gain less than 10 pounds.[55] Although such weight gain has a negligible harmful impact on health, weight concerns and intolerance of weight gain are associated with early relapse.[56,57]

As many as 75% of women and 35% of men have indicated their unwillingness to gain more than 5 pounds if they quit smoking.[58] Among women under the age of 25, more than half (57%) are unwilling to gain any weight; by contrast, only 39% of women over the age of 40 are unwilling to face added pounds it they stop smoking.[58] Efforts to assist patients with weight control during smoking cessation that use behavioral weight-control strategies have not been successful.[59] Research findings suggest that programs with regular physical exercises are helpful for those who can comply.[60]

The Guideline recommends openly acknowledging the likelihood of weight gain. Furthermore, the significance of such patients’ feelings about weight gain should be respected. One approach to handling this concern is to urge the patient to wait and see.[58] This approach involves delivering accurate information about weight gain and informing patients that some individuals might have a different experience. The other approach is the single-focus approach that encourages patients to focus on smoking cessation first and defers focus on weight management until the patient is able to maintain abstinence from smoking.

Using nicotine gum to reduce the rate of weight gain during the early course of quitting is also recommended by the the Guideline.[1] Results of previous research indicate that smokers who use nicotine gum experience less short-term weight gain, but that there is no difference in weight gain beyond 6 months.[61] This approach might alleviate patients’ initial anxiety about gaining weight.

We agree with the Guideline’s recommendation that patients’ concerns about weight gain should be addressed openly during the early phases of quitting. Patients should be encouraged to strive not to substitute eating for cigarette smoking and should be provided with alternative strategies. Increased physical activity (using the stairs more often, parking farther from stores or offices) are ways to combat postcessation weight gain. Some patients may resist this suggestion because they perceive it as asking them to engage in a new exercise routine. Therefore, this recommendation should be clarified, reinforced, and repeated as needed.

Additional Techniques

Cinciripini and colleagues[62] developed the “scheduled smoking procedure” with or without gradual reduction and found that it produced outstanding cessation rates (44% with gradual reduction, 32% without at 1-year follow-up) compared with gradual reduction alone (18%) or “cold turkey” (22%).

Patients using the scheduled smoking approach are instructed to smoke only at specific times of the day. Smoking can take place only during the first 5 minutes before or after the scheduled time. “Missed” cigarettes cannot be accumulated for later use. If a patient smokes 30 cigarettes per day over a 15-hour span, the patient’s schedule of smoking will be 1 cigarette every 30 minutes. In the case of gradual reduction, Cinciripini and colleagues used an algorithm to lengthen the intercigarette interval gradually by reducing the smoking rate by one third each week.

More research to examine the effect of the scheduled smoking approach is under way. However, providers may consider using this method before the patient’s quit date. Furthermore, this technique may be used as an alternative strategy for patients who are inappropriate candidates for NRT.

Putting Components Together

How long should an effective smoking cessation intervention be? The Guideline[1] suggests that an intervention as short as 3 minutes can be effective. If resources allow, 4 to 7 sessions of 20 minutes to 30 minutes each over a minimum of 2 weeks is recommended. Interventions may be implemented in both individual and group formats, which have been found to be equally effective.[1] Researchers have also reported some success with a telephone-counseling format, which is well received by patients.[54,63-65]

Although written materials standing alone are not effective,[1] we recommend providing supplementary literature along with more comprehensive treatment. Written materials serve as reminders and are a supplement to counseling because they are accessible to patients at all times and allow the patient to refer to the materials as needed.

The traditional self-help approach, using only written self-help materials, has been found to be ineffective[1] because individuals were usually given all the information all at once, with no guidance. If providers deliver concise information at the patient’s pace, perhaps the provider could help prevent patients from becoming overwhelmed with the stress of quitting.

For an example of a smoking cessation program adapted from the one we are currently using in our clinic, see Table 4. The program can be conducted in either an individual or a group format and in both brief and intensive fashion when supplemented with written materials (handouts). This sample program is composed of 6 sessions over 9 weeks, with the target quit week at the 3rd visit, and a 6-week regimen of patch use.

TABLE 4

A Sample Program for Smoking Cessation Treatment

Time Session Description

Week 1 1 Introduction: Smoking and you,

benefits of quitting

Reasons for smoking and quitting

Set a target quit date

Week 2 2 Preparing for quit date

How the patch works and proper

use of the patch

Use patch as instructed on target

quit date

Week 3 3 Handling withdrawal

(target quit date) Fighting the urge to smoke

Identifying tempting solutions

Use patch

Week 4 4 Conquering tempting solutions

Patch use

Week 6 5 Managing stress without smoking

Patch use

Week 9 6 Maintain long-term abstinence

Terminate patch use if appropriate

Note. Follow-up contacts focus on relapse prevention at 1 month, 3 months, 6 months, and 1 year.

Regardless of the setting or format, patients should be encouraged to discuss their concerns or problems with smoking cessation freely, despite the structure of the program (supportive component). Discussion should be followed immediately by skills training, when appropriate. Follow-ups and continued contacts are important. Brief phone contacts and open follow-up sessions are also helpful to address postcessation concerns.

In sum, smoking cessation interventions can range from simple advice to quit to more comprehensive treatment. A review of the literature suggests that a combined approach incorporating NRT, provider support, and skills training is the most effective intervention. In this review, we have offered these components to practitioners in a practical, how-to format.

Providers with different specialties should consider delivering interventions in the areas with which they are most comfortable. Minimally, practitioners should provide supportive care to smokers, despite the patient’s lack of readiness to quit smoking. Referral to formal and intensive smoking cessation should be routinely made for individuals who express interest in obtaining help in quitting.

We hope that this material will help facilitate the provision of smoking cessation services to those who need it. Smoking cessation is cost-effective and essential at all levels of healthcare.[66] Failure to provide even a minimal intervention to smokers is unjustifiable and represents negligence in providing healthcare.

NOTE

For further information, please write to Janice Y. Tsoh, PhD, 5501 Reseda Circle, Fremont, CA 96538.

ACKNOWLEDGMENT

The authors would like to thank Dr Karen Cullen at UT MD Anderson Cancer Center for reviewing this manuscript.

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Drs Tsoh, McClure, and Skaar are postdoctoral fellows in the Department of Behavioral Science, Division of Cancer Prevention at University of Texas MD Anderson Cancer Center in Houston, where Dr Cinciripini is an associate professor in the Department of Behavioral Science and director of the Tobacco Research and Treatment Program, and Drs Wetter and Prokhorov are assistant professors. Ms Friedman is a counseling psychology graduate student at the University of Houston. Dr Gritz is chairman of the Department of Behavioral Science, Division of Cancer Prevention at UT MD Anderson Cancer Center.

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