I. Self-Help Material

OBJECTIVE

To assist the person in learning about the benefits of quitting.

ANNOTATION

Provide the person with self-help material. Provide Primary Care Managers (PCM)s and Primary Care Providers (PCP)s "How to" literature and a list of established "stop smoking" programs available. (See Appendix 4, Self-Help Material).

DISCUSSION

Following completion of the treatment, relapse prevention becomes the most important factor in determining success in the cessation of tobacco use.^{38, 39}

EVIDENCE

LE = C, SR = I Hurt 1997, Fiore 1996

REFERENCES

³⁸ Fiore 1996 p. 63; ³⁹ Kenford et al. 1994

J. Initiate/reinforce Relapse Prevention

OBJECTIVE

To reinforce and motivate abstinence from tobacco and prevent future relapses (tertiary prevention).

ANNOTATION

Most tobacco relapses occur within the first three months after cessation, but some relapses occur years after quitting. Telephone calls, clinic visits, or any time the clinician encounters a former tobacco user can be appropriate times to accomplish intervention for relapse prevention. Minimal relapse prevention should be part of every primary care encounter with persons who have recently quit. Minimal reinforcement approaches can be expressed as:

1. Offer congratulations on quitting.
   
   
2. Encourage the person to continue tobacco free.
   
   
3. Encourage active discussion of the benefits of quitting by asking the person open-ended questions designed to include the person's problem solving on:
   
   
   1. Anticipated health benefits derived from cessation.
      
      
   2. Success the person has had in quitting.
      
      
   3. The most notable tobacco withdrawal symptoms experienced.
      
      
   4. Problems or threats anticipated or encountered while maintaining abstinence (e.g., weight gain; negative mood, depression, or anxiety; prolonged withdrawal symptoms; and lack of social support for cessation.
      
      

DISCUSSION

The purpose of relapse prevention may need to be individualized especially during the first three months of abstinence.^{40, 41} Some relapses occur years after quitting.⁴² Intervention may need to be individualized based on problems experienced by the person while maintaining abstinence. The more intensive interventions may be delivered through the PCM/PCP, specialized clinic, or program. The components of intervention may include addressing:

1. Weight gain ¾ The clinician can give dietary, exercise, or lifestyle recommendations; or refer the person to a specialist or program. The person should be reassured that some weight gain after quitting is common and that imposing significant dietary restrictions soon after quitting may be counterproductive.
   
   
2. Negative mood, depression or anxiety ¾ If significant, the clinician might prescribe appropriate medications or refer the person to a mental health specialist.
   
   
3. Prolonged withdrawal symptoms ¾ If the person reports prolonged craving or other withdrawal symptoms, the clinician might consider prescribing pharmacological therapy as appropriate.
   
   
4. Lack of social support for cessation ¾ The clinician can help identify sources of support within the person's environment or refer the person to an appropriate organization offering cessation counseling or support (e.g., Nicotine Anonymous).⁴³

EVIDENCE

LE = C, SR = I Kenford et al. 1994, U.S. DHHS 1994, Hatziandreu 1990,

REFERENCES

⁴⁰ U.S. DHHS 1994; ⁴¹ Hatziandreu 1990; ⁴² Kenford et al. 1994; ⁴³ Brandon et al. 1986