Phases of Treatment
The general approach to the treatment of nicotine dependence considers three phases of treatment (engagement, quitting, and relapse prevention) (Table 42.2).
The importance of each of the biopsychosocial factors in initiating and maintaining smoking can vary considerably in dif-ferent individuals. As a result, smoking cessation interventions should be tailored to the individual and his or her particular circumstances. This may be one reason why “one size fits all” generic treatment interventions have had such a low success rate. It must also be kept in mind that nicotine dependence is as complex in its components and determinants as other addictions and that more comprehensive multicomponent treatments may be required. When a smoker is ready for a cessation attempt, a “quit date” should be selected. After cessation, close monitoring should occur during the early period of abstinence. Before the quit date, the person should be encouraged to explore and organ-ize social support for the self-attempt. Plans to minimize cues associated with smoking (e.g., avoiding circumstances likely to contribute to relapse) are important, as is considering alterna-tive coping behaviors for situations with a higher potential for relapse. A telephone or face-to-face follow-up during the first few days after cessation is critical because this is the time that with-drawal symptoms are most severe, with 65% of patients relapsing by 1 week. A follow-up face-to-face meeting within 1 to 2 weeks allows a discussion of problems that have occurred (e.g., difficul-ties managing craving) and serves as an opportunity to provide reinforcement for ongoing abstinence. Even after the early period of abstinence, periodic telephone or face-to-face contacts can provide continued encouragement to maintain abstinence, allow problems with maintaining abstinence to be addressed, and pro-vide feedback regarding the health benefits of abstinence.
If an initial attempt at cessation using only information and brief advice from the physician has been unsuccessful, phar-macotherapy may be used unless contraindications are present or unless the person has had few or no significant withdrawal symptoms. The most common pharmacotherapy approaches are nicotine replacement therapies (NRTs: patch, gum, spray, or in-haler) or bupropion for nicotine dependence. Combining differ-ent types of NRT and bupropion is becoming more common in clinical practice, including using these medications for at least several months and in some cases 1 year or longer. Maintenance medications are being considered in an effort of harm reduction in a more select group of patients. If a detoxification/quit attempt with pharmacotherapy alone fails, psychosocial treatments and the use of higher NRT dosages/multiple medications are possi-ble clinical next steps. Psychosocial treatments are often avail-able through organizations such as the American Cancer Society, American Lung Association, the American Heart Association, or through local hospitals that provide health prevention and public education programs (American Cancer Society/National Cancer Institute, 1989). If pharmacotherapy is unacceptable or con-traindicated, behavioral therapy (BT) alone should be provided. Failure with pharmacotherapy or BT alone suggests the need for more detailed in-depth assessment and more intensive and mul-timodal interventions.