Statistics show that relapsed smokers stand a better chance of succeeding on their next attempt than people who have never tried to quit through determination and learning about managing cravings.

Clinicians are applying new insights to the treatment of relapsed smokers. According to smoking cessation counselor Lourdes Gomes, tobacco treatment specialist for the Cambridge Health Alliance in Somerville, Mass, smoking cigarettes is much like being trapped in an abusive relationship. You are fully aware of the harm it is doing to you, yet there are small things you like about the person and about the relationship that carry you from day to day. Sometimes there is a crisis when you realize your safety is at risk, but then the crisis is over, and you put off leaving. Or you leave, but then you go back.

“You are stuck,” Gomes explains. It is her way of understanding smokers who say they want to quit, but seem powerless to do the very things that would set them free. And it makes sense to her clients, most of whom have tried to quit, but returned to smoking when they experienced withdrawal, or when they realized that lighting up a cigarette was the only way they knew to manage the stress in their lives.

“Yes, these are relapsed smokers,” Gomes concedes, who rarely uses the term because to her it sounds judgmental, “as though they have gone back to a life a crime.” From a clinical standpoint, however, she recognizes relapsed smokers as a distinct group with complex needs. They are the majority of her clientele.

They also represent the majority of people who successfully stop smoking, according to Thomas L. Petty, MD, chairman of the National Lung Health Education Program and professor of medicine, University of Colorado Health Sciences Center, Denver. “On average, depending on which studies you look at, people quit three to seven times before they finally stop smoking cigarettes permanently,” Petty says. Whether it is because they are more determined or they have learned a few things about managing cravings, statistics show that relapsed smokers stand a better chance of succeeding on their next attempt than people who have never tried to quit before. At the same time, the very fact that these individuals have relapsed indicates that they face significant barriers to becoming smoke-free. According to Petty, the first task of the clinician must be to discover what these barriers are.

“The probability is that such patients are highly addicted,” Petty says. In his view, smoking is as powerfully addictive as narcotics or alcohol. Smoking addiction derives its extraordinary power, not merely from the pharmacologic addiction to nicotine—which in itself is real—but also from the way almost every activity of daily living becomes a cue to smoke.

“Often, these cues are not even recognized by the individual. These may be as simple as a telephone call, a coffee break, a pleasant meal, or following sexual activity,” Petty says.

“Sometimes boredom, delays in traffic, or other frustrations are signals to light up once again.” As if this were not enough, smoking is also a social activity. “To overcome addiction at the same time one gives up the camaraderie of smoking with friends, that’s a real challenge,” Petty says.

Intervention
He learned just how challenging it can be several years ago, when he decided to start a smoking cessation clinic of his own.

“I thought that because I was able to help severe asthmatics manage their asthma, I should be able to help people stop smoking,” Petty recalls ruefully. “I enrolled 33 consecutive patients who had failed at least once to stop smoking in a program they had paid for, such as formal classes, acupuncture, or hypnosis. This was the criterion we used to identify them as addicted smokers.

“I said to myself that I want to see how many I can get to quit in 1 year. This was before the nicotine patch and bupropion. The motto of our clinic was, ‘I won’t quit until you do.’ At the end of 1 year, exactly three people had quit out of the 33. Of those, one was severely depressed and one died of lung cancer within the year. So in reality, only one person really benefited from the intervention.”

Today, Petty would prescribe nicotine replacement for such addicted smokers. Currently, he says, using higher doses of nicotine via patch or gum, and giving patients a nasal spray or nicotine inhaler along with a patch, are becoming accepted approaches.^1,2 Combination therapy with nicotine and the antidepressant bupropion is becoming commonplace. According to Petty, provided patients have a solid quit plan in place, nicotine replacement can double their chances of success.³ Thus, addiction scoring should be the first step in any assessment of a patient for smoking cessation. Clients for whom the first cigarette of the day is the most necessary and pleasing, or clients who smoke more than one pack per day, should be considered addicted. Some addicted smokers even wake up briefly during the night for a quick cigarette, so-called “nocturnal smoking.”⁴

Although nicotine patches and gum are available over the counter, many lay counselors like Gomes ask clients to obtain a signed prescription from their primary care provider. “Since we do not have access to their medical records, this ensures that they do not have any contraindications to nicotine replacement, such as hypertension,” Gomes says. However, she does not let the discussion of nicotine replacement take time away from helping the client to develop an effective quit plan. She finds that there are many people who try unsuccessfully to quit on their own and come to the clinic to “get the patch,” but who really need guidance in developing a plan and setting a quit date.

Behavior Modification
“Behavior modification needs to be offered to every patient, regardless of whether pharmacologic agents are prescribed as part of the stop-smoking strategy,” Petty agrees. He points out that most people quit on their own, and they do it cold turkey. One day they smoke and the next they do not. Of course, this does not mean that they do it without behavior modification. It simply means that they are able to analyze their own cues to smoke and change their routines sufficiently to avoid those cues. “A physician’s or other health care professional’s advice to stop smoking, which requires only a few minutes, will often achieve a 3% to 5% quit rate,” Petty notes.

For Gomes, this raises an important question for her practice. Since so many people do quit on their own, what is different about the people who seek help, or who are referred to smoking cessation clinics? What does the clinician have to offer that clients cannot provide for themselves?

Gomes gives her clients written materials and narratives by people who have successfully quit smoking, describing what they have done to help themselves. There seem to be as many ways of coping as there are people who have quit. Then she talks with clients about their circumstances to find out what might make it difficult to put coping strategies into play.

“I try to empower people,” Gomes says. She listens carefully when a client analyzes the way smoking is part of his or her daily routine, and she tries to identify the emotions that awaken the desire for a cigarette. “The emotions are the difficult part,” she says. The more experience she gains working with people who are trying to quit, the more time she spends with each client developing new outlets for these emotions.

Smoking Patterns
When Gomes talks to clients about their smoking pattern, she also asks about relapse. Did they ever quit in the past? Why did they resume? Was it the cigarette left burning on the bar that was just too tempting? The stress of being told their child needed surgery? Being unable to concentrate at work? Once she identifies what triggered the relapse, she helps the client explore ways to prevent the same thing from happening again.

Gomes makes suggestions for changing daily routines to eliminate cues to smoking. “One thing that scares many smokers is the thought of being without a cigarette and making changes in their routine at the same time. So I tell them that you can still smoke, but try to change the order in which you do things, especially in the first few hours after waking up. That way, you can trick your mind by delaying the first cigarette. For example, I may suggest that they take a shower first, or maybe they can have breakfast first instead of lighting up as soon as they get out of bed. Or get up and out of the house right away,” Gomes says.

Other clients may be afraid to make changes. “I tell them first to quit smoking, then they can make other changes. In other words, I try to find and suggest things the clients can do, not simply things that have worked for other people,” Gomes says.

Over time, she has learned the value of letting clients construct their own treatment plan. “I try to give people options and let them decide how they want to do it,” she says.

Motivation After Relapse
What motivates someone who has relapsed to try again?

“Often it is because a condition such as bronchitis has gotten worse, or because someone in the family has died of lung or heart disease,” Gomes says. She tries to strengthen this motivation with use of the carbon monoxide monitor. “When people see the change before and after quitting smoking, they are really happy,” she says. Clients may not even sense the change. “But by using the machine, they can visualize their bodies getting more oxygen. This is a really strong motivator,” she says.

According to Gomes, when a child develops respiratory problems such as asthma, parents may feel pressure to quit smoking. Yet they may not be ready to go that far. “I am working with a couple now whose son has ear infections. Both the mother and the father are still smoking, but they no longer smoke in the house, and that has helped,” Gomes says.

According to Alisa French, MBA, RRT, RCP, health promotion coordinator at The Children’s Medical Center, Dayton, Ohio, the fact that a client is not ready to stop smoking should not prevent a clinician from offering useful interventions. Currently, her group is developing a program to guide respiratory therapists in talking with parents about second-hand smoke. “We ask if they are willing to quit. If not, we give them a handout on things they can do to reduce their child’s exposure to second-hand smoke. The handout is a checklist and we ask them to check if they are willing to smoke outside (not in the house), and if they are willing not to smoke in their cars,” French says.

Teen Smoking
In 1995, after running a smoking cessation program for adults for several years, French and her colleagues were invited to develop a program for teens. Clients in the program are referred by parents or school authorities after being caught smoking on school grounds. “Many kids feel they are being punished, so they don’t want to be there; however, some join voluntarily,” French says. One girl joined because her friend was in the program so she wanted to quit also.

French has found that many teens would like to quit even though they entered the program under duress. Quite a few have tried to quit before. “I do addiction scoring with them, and of course, most of the kids who come to the program are addicted,” she notes. If they are strongly motivated to quit, French encourages them to try nicotine replacement therapy.

According to French, adolescents can become addicted very quickly. When their family smokes, and especially when their peer group smokes, they face a double deprivation if they want to stop. For the teens in her program who are serious about quitting, she makes sure they avoid alcohol during the early weeks and are ready with a plan to take a walk or otherwise get away temporarily when others light up.

She insists that all the participants make an attempt to quit primarily so they can discover where the pitfalls lie. One thing that often causes girls to relapse is weight gain. For this reason, French tries to introduce healthy eating along with quitting and encourages teens to increase their exercise. “Teens are under a lot of stress and exercise is one of the best ways to deal with that,” she says.

Weight Gain
According to Petty, weight gain can be a major barrier to smoking cessation since some women use smoking as a form of weight control. Such women may resume smoking if they start to gain weight. Although studies suggest that giving up nicotine triggers metabolic changes, many people also nibble on snacks as a substitute for cigarettes. Petty advocates increasing exercise to offset the metabolic tendency to put on weight and advises patients to use healthy snacks instead of those high in calories.

He believes that clinicians should be proactive in addressing weight gain before it gets out of hand. Both nicotine replacement and bupropion may also help to prevent weight gain.⁵

Depression
According to Petty, many smokers use nicotine to control depression; a few of these individuals can be plunged into a serious illness when they try to quit smoking. This was brought home to him by the case of a woman who stopped smoking under his guidance only to become potentially suicidal. “I was shocked when I received a call from her psychiatrist—I hadn’t even known she was seeing a psychiatrist,” he recalls. In his view, candidates for smoking cessation should be screened for depression and those at risk should be placed on bupropion before they actually stop.

“In general, people feel better when they quit smoking, but there is a subgroup of people who actually feel worse. It may be that the nicotine had been alleviating some depression in those people,” says Lirio Covey, PhD, director of the smoking cessation clinic at Columbia University in New York.

Covey would like to see clinicians assess clients, not only for depression, but also for anxiety disorders, attention deficit, and alcohol problems. Ideally, pharmacotherapy, length of therapy, and even the type of counseling might be tailored to clients with these types of conditions.⁶ “For example, psychologically oriented counseling might be welcomed by this group, whereas most clients for smoking cessation would be turned off by that,” Covey says.

Relapse Prevention
Currently, she is enrolling smokers in a federally funded study of relapse prevention. Initially, all the volunteers, who must have quit smoking at least once in the past, will receive nicotine patches, bupropion, and counseling. Those who have successfully quit smoking at the end of 8 weeks will move into an experimental phase, in which some patients will continue to receive active drugs for 3 more months, while others will be randomly assigned to receive placebos. Counseling will continue. Covey and her colleagues hope to learn whether extending combination therapy in this manner can reduce the relapse rate.

“We know from previous studies that no matter what kind of treatment people get, the slope—the relapse rate—is the same. If you start with 60% who have quit, at the end of 6 months you are down to 30%. If you start with 40%, it drops to 20%. We hope to flatten that relapse curve,” Covey says. She and her colleagues will look at weight gain, mood changes, and other side effects of stopping smoking to see how these are associated with relapse.

Covey will also try to determine whether extending treatment with a high level intervention—two drugs and counseling—is cost-effective. “That is why we are looking at people who have tried and failed. People who can quit on their own don’t need this level of treatment,” Covey says.

Are relapsed smokers also more likely to succeed than people who are trying to quit for the first time? Covey says yes. They have withstood cravings, at least for a time, and they have learned behavioral techniques that will be useful in their particular lifestyle.

Petty agrees. “But in a sense, this is a self-selected group,” he says. “Those who don’t try anymore will never get free. The ones who keep trying will finally make it.”

India Smith is a contributing writer for RT Magazine.

References
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6. Covey LS. Nicotine dependence and its associations with psychiatric disorders: research evidence and treatment implications. In: Seidman DF, Covey LS, eds. Helping the Hard-Core Smoker: A Clinician’s Guide. 1st ed. Mahwah, NJ: Lawrence Erlbaum Associates; 1999:23-51.