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Strategies for effective relapse prevention

Patricia Hodgson
MSc Nutrition
Health Promotion Specialist Calderdale and Kirklees Smoking Cessation Service Princess Royal Health Centre Huddersfield
West Yorkshire Smoking and Health Coordinator

Smoking cessation is the "gold standard" of health promotion. The cost of smoking cessation per life year gained is less than 0„5800; the National Institute for Clinical Effectiveness (NICE) has been using 0„530,000 as a benchmark for recommending new treatments.(4)
 
Relapse prevention therapy
Relapse prevention therapy (RPT) is a behavioural self-control programme aimed at changing behaviour and anticipating and coping with relapse. The general consensus is that preventing relapse in smoking cessation includes pharmacological therapies working in tandem with cognitive-behavioural therapies - that is, thinking and doing something when tempted to smoke.(5-8) RPT during the first year involves three phases:(6,9)

  • Stage 1 - management of acute nicotine withdrawal During the first two weeks of quitting, 25-30% may relapse, largely due to acute nicotine withdrawal. The advisor must implement acute nicotine withdrawal management, ensuring that pharmacological therapy, if prescribed, is being used as directed, and provide reassurance that symptoms ease after the first two weeks and that they are a sign that the body is healing after the damage caused by years of smoking.
  • Stage 2 - acute relapse prevention  From two weeks to three months, another 40-50% of quitters may relapse. Since this is primarily due to psychological withdrawal, the advisor needs to implement acute relapse prevention activities. Delivery may be by one-to-one appointments, booster sessions or telephone counselling.(10)
  • Stage 3 - relapse maintenance  From three months to one year relapse starts to dwindle, especially after six months. However, another 15-20% will relapse before the end of the year. This is the relapse management phase, when the advisor needs to help the quitter maintain determination, be prepared for unexpected trigger situations and avoid overconfidence.

Relapse prevention strategies
To prevent relapse, changes on three levels are required: physiological (coping with nicotine withdrawal); behav-ioural (extinguishing smoking-conditioned behaviours and establishing substitute behaviours); and psychological (dealing with emotional changes and managing negative life events without smoking).(9) The following are recommended strategies for relapse prevention:(8)

1. Ensuring patients understand that stopping smoking may involve slip-ups and relapses
The common fear that discussing relapse might give the patient permission to fail is misguided.(7) Smokers need to realise the likelihood of relapse and the importance of "recycling" back into the quitting process as soon as possible. The "all-or-nothing" message (ie, one cigarette and you are a smoker again) needs to be replaced by the appreciation that stopping smoking takes time, involving on average three to four attempts to quit.(10,12-14)
Reassure patients that, although complete abstinence is the best, slip-ups are part of the process of quitting.

2. Enhancing feeling of being in control
The cornerstone of RPT is enhancing two perceptions: feelings of being in control ("It is my choice to stop smoking") and self-efficacy ("I can do it. I have the power within me to quit").(8,14)
Offer congratulations for success achieved; review the reasons for stopping and the benefits of stopping. 

3. Identifying early warning signs of a relapse
A relapse is usually the last link in a chain of events that starts with a number of predisposing factors or warning signs.(8)     Help patients spot these by inquiring about new or unusual feelings or reactions since the last session, "Have you noticed any changes in the way you feel since you stopped smoking?"
Feeling deprived of the pleasures of smoking  People are "conditioned" to remember pleasures in life and repress painful life events. After quitting smoking, people start to remember what they liked about it and forget what they disliked. Feelings of deprivation emerge and they think that they are losing more than they are gaining.
Review the reasons for quitting to remind them of why they stopped. Help them realise that they are gaining more from quitting than they have lost.
Experiencing strong psychological cravings  People may complain of irresistible cravings for a cigarette, which may be far worse than those felt when first quitting. This is not only due to the natural inclination to forget painful experiences, but also due to feeling unsatisfied because immediate cravings are not being gratified.
Offer reassurance that cravings usually go away within several minutes. Enhance feelings of self-liberation and self-efficacy. Identify fulfilling alternative activities to replace smoking. If on pharmacological therapies, make sure they are being used as prescribed.
Having doubts about quitting  As the initial excitement decreases, motivation begins to erode. Regret at having made the decision to stop smoking may emerge.
Encourage the patient to take "one day at a time"; short-term goals are easier to maintain motivation. Identify rewards for stopping smoking.
Overreacting to negative situations and emotions  Smoking is often used as a ''quick fix" to deal with painful emotions. Without cigarettes to numb strained nerves, the individual may overreact uncharacteristically.(5,9)
Help the individual to identify satisfying ways of coping with negative feelings. If using pharmacological therapies, make sure they are being used as prescribed.
Tired of resisting triggers to smoke  Most of life's activities are done automatically.(7) Individuals may soon become weary of having to redirect mental energies from other aspects of life towards resisting triggers to smoke.
Review coping strategies to ensure that they are comfortable and easy to put into action. The strategies should be well rehearsed so that they are automatic behaviours, requiring little conscious thinking.

4. Identifying high-risk situations
A slip-up is often precipitated by a high-risk situation.(8,10) Risky situations can be anticipated, but they may occur when least expected. Even if a coping strategy is in place, it may not be put into action because mental energies are diminished.
Identify potential high-risk situations, not just obvious ones, but also potentially unexpected ones. Over 75% of relapses are associated with negative emotional states (bereavement, anger, frustration, stress), interpersonal conflict (major family problem, argument with a loved one) and social pressures (being with other smokers in social situations, especially if alcohol is also present).(7,9,10)

5. Coping strategies for high-risk situations
Effective coping strategies include both thinking and doing activities.(5) Ensure that coping strategies enhance feelings of self-liberation - "I have the choice to smoke or not to" - and self-efficacy - "I have the strength within me to cope with high-risk situations". Identify activities to replace smoking, such as the five "Ds" - Do something else, Delay smoking, Drink water, Deep breathing, Dial the NHS Smoking Helpline - 0800 1690169.

6. Learning damage limitation procedures following a slip-up
A slip-up will turn into a full-blown relapse if a patient feels personal blame for the lapse, that quitting is "all-or-nothing" or that smoking will produce a positive outcome (eg, "Smoking will make me feel less anxious").(7,8,10)
Describe slip-ups as due to an inadequate coping strategy to a high-risk trigger, and not due to anything lacking within the individual. It is just a minor setback. Identify changes that may need to be made to the strategy and highlight the negative consequences of returning to smoking, "How do you think you will feel if you start smoking again? What would it do to your health?"

7. Recycle back into the quitting process
If an individual has a full-blown relapse and returns to their usual smoking habits, urge them to see relapse not as a sign of failure. Encourage them to see it as a challenge, and to learn from the recent quit attempt so that the next one has a higher chance of success.
Review why the relapse happened. Suggest taking a short break and then phoning you in 3-6 months to make another attempt. Encourage patients to recycle back into the quitting process as soon as possible.(10)
When relapsers are aware that a trusted health professional has faith in their ability to quit and is willing to provide nonjudgmental support, no matter how many quit attempts they've had, it may provide them with the extra confidence needed to make another attempt.

References

  1. Fiore M. Treating tobacco use and dependence: clinical practice guidelines. Washington, DC: US Department of Health & Human Services; 2000.
  2. Orleans C, Slade J, editors. Nicotine addiction: principles and management. Oxford: Oxford University Press; 1993.
  3. Irvin JE, et al.  J Consult Clin Psychol 1999;67:563-70.
  4. Stapleton J. Cost effectiveness of smoking cessation services. Personal communication; August 2001.
  5. Seidman D, Covey L. A comprehensive psychological approach to preventing relapse. In: Seidman DF, Covey LA, editors. Helping the hard-core smoker. London: Lawrence Erlbaum; 1999.
  6. Lando H. Update on smoking cessation. Paper presented at conference, University of Minnesota, USA, Aug 2001.
  7. el-Guebaly N, Hodgins D. Can J Psychiatry 1998;43:29-36.
  8. Parks GA, Marlatt GA. National Psychologist 2000;9:5.
  9. Covey L. A psychotherapeutic approach for smoking cessation counselling. In: Seidman DF, Covey L, editors. Helping the hard-core smoker. London: Lawrence Erlbaum; 1999.
  10. Curry SJ, McBride CM. Annu Rev Public Health 1994;15:345-66.
  11. Marlatt G, Gordon J, editors. Relapse prevention: maintenance and strategies in the treatment of addictive behaviours. New York: Guilford Publications; 1985.
  12. Prochaska JO, DiClemente CC. J Consult Clin Psychol 1983;51:390-5.
  13. Prochaska JO, DiClemente C. Staying free from smoking: learning from relapse. University of Rhode Island; 1987.
  14. Ahijevych K, Wewers ME. Addict Behav 1992;17:17-25.

Resources
West Yorkshire Smoking & Health (WYSH)
has developed a relapse prevention leaflet -
Learning to stay stopped
For a complimentary copy, send an A5 SAE to:
Patricia Hodgson
WYSH
Princess Royal Health Centre
Greenhead Road
Huddersfield
HD1 4EW
Quit
T:020 7251 1551
Quitline
0800 002200