N. Assess Risk for Relapse

OBJECTIVE

To assess former tobacco user's risk of relapse and determine if relapse prevention counseling is advisable at this stage.

ANNOTATION

Tobacco use has been characterized as a chronic relapsing disorder due to the high frequency of relapse after a single quitting attempt. Indeed, relapse rates of up to 89 percent are expected among previous tobacco users who have achieved cessation after a single quitting attempt, cold turkey. However, cumulative success rates over multiple quitting attempts may improve the success rate.

DISCUSSION

The majority of relapses occur relatively early in the quitting process. The length of time a person has been abstinent at the time of the health care visit is an important factor in assessing a person's risk of relapse. Although relapse has been seen even after one or more years of abstinence, the relapse rate falls significantly after three months.⁴⁷ Individuals who have been abstinent for under three months at the time of the visit should be considered at risk for relapsing and viewed as candidates for relapse prevention counseling. This is especially true if they have had slips (sporadic episodes of tobacco use) early in the quitting process, since one or more slips after cessation predicts relapse. Nevertheless, three months should not necessarily be considered a safe point since relapse can and does occur after this point. Persons fitting any of the parameters below should be considered candidates in need of relapse prevention counseling:⁴⁸

1. Various individual factors relate to an increased likelihood for relapse:
   
   
   1. Negative emotional states, e.g., stress, depression, anxiety, etc.
      
      
   2. Concern about post-cessation weight gain.
      
      
   3. The presence of significant craving and/or withdrawal symptoms.
      
      
   4. Present or past history of substance use disorder.
      
      
   5. Previous quit attempts.
      
      
   6. Unaware or unconcerned about issues related to relapse.
      
      
   7. Does not attempt to modify his or her environment.
      
      
   8. Engages in "risky behavior" such as consumption of alcohol or other mind-altering substances.
      
      
   9. Attends establishments where smoking is tolerated, even encouraged, e.g., bars.
      
      
2. Social and environmental factors also appear to be related to relapse:
   
   
   1. Use of tobacco is socially accepted and legal.
   2. Presence of other tobacco users.
   3. Lack of social support for quitting.
   4. Visual cues related to the advertising of tobacco products.
   5. Easy access to tobacco products.

REFERENCES

⁴⁷ U.S. DHHS 1994; ⁴⁸ Brownell et al. 1998

O. Initiate Prevention

OBJECTIVE

To educate potential tobacco users and prevent them from ever starting (primary prevention).

ANNOTATION

There are many reasons to address prevention in the early and middle school age groups. This group of children and young adults are very susceptible to adult role models and peer pressure. Tobacco use prevention pamphlets can be very informative and address age appropriate issues.

DISCUSSION

Suggested focused interventions for PCM/PCPs to prevent initiation of tobacco use:

1. Early elementary school.
   
   
   1. Ask the child whether he or she has experimented with tobacco.
      
      
   2. Discuss tobacco use and its addicting effects¾ especially the short-term negative effects.
      
      
   3. Identify the advantages of not smoking, including those most appropriate for the child's age and developmental stage.
      
      
   4. Explain that he or she eventually may encounter peers who use tobacco and discuss ways in which he or she might resist peer pressure to try tobacco products.
      
      
2. Middle school/Junior high school.
   
   
   1. Reassure him or her that most kids don't use tobacco including smokeless tobacco.
      
      
   2. All forms of tobacco (snuff, cigarettes, dip, etc.) are extremely addictive, and most teens who use tobacco are addicted to nicotine.
      
      
   3. Addiction to tobacco takes away one's independence.
      
      
   4. Smokeless tobacco is not a safe alternative to tobacco use, because it is addicting, causes oral cancer, and damages teeth and gums.
      
      
   5. Tobacco use makes a person's:

      1) Mouth, hair, and clothes smell bad.

      2) Teeth and skin become stained.

      3) Clothes are ruined, burned holes.

      4) Causes shortness of breath.

      5) Decreases athletic performance.

      6) Is a major cause of fires and deaths.

   6. Tobacco use causes health problems in many young people, including chronic cough and sore throat.
      
      
   7. Tobacco use won't make a person rugged, sexy, "cool," or successful.
      
      
   8. Tobacco use is a gateway to other drug use, and addiction to nicotine may make a person more susceptible to trying other dangerous drugs.
      
      
   9. Tobacco use is an increasingly expensive habit taking money needed for other things (e.g., books, clothes, makeup, music, movies, and sports).
      
      
   10. There are other ways of being different without taking up a habit that is addicting and has such severe, long-term consequences.^{49, 50}

EVIDENCE

LE = C, SR = I U.S. DHHS 1994, Fiore et al. 1996

REFERENCES

⁴⁹ Fiore et al. 1996; ⁵⁰ U.S. DHHS 1994