Preventing and Quitting Substance abuse

1. Preventing and Quitting Substance abuse Smoking

2. DiClemente et al 1991 • A study to examine the stages of change in predicting smokingcessation • DiClemente and Prochaska (1982) developed their transtheoretical model of change to examine the stages of change in addictive behaviours. This study examined the validity of the stages of change model and assessed the relationship between stage of change and smoking cessation.

3. The stages of change model • The stages of change model describes the following stages: • * Precontemplation: not seriously considering quitting in the next 6 months. • * Contemplation: considering quitting in the next 6 months. • * Action: making behavioural changes. • * Maintenance: maintaining these changes.

4. The stages of change model • Subjects • 1466 subjects were recruited for a minimum intervention smoking cessation programme from Texas and Rhode Island. The majority of the subjects were white, female, started smoking at about 16 and smoked on average 29 cigarettes a day.

5. The stages of change model • Design The subjects completed a set of measures at baseline and were followed up at 1 and 6 months

6. The stages of change model • Measures The subjects completed the following set of measures: • * Smoking abstinence self-efficacy (DiClemente et al. 1985), which measures a smoker's confidence that they will not smoke in 20 challenging situations.

7. The stages of change model • * Perceived stress scale (Cohen et al. 1985), which measures how much perceived stress an individual has experienced in the past month. • * Fagerstrom Tolerance Questionnaire, which measures physical tolerance to nicotine.

8. The stages of change model • * Smoking decisional balance scale (Velicer et al. 1985), which measures the perceived pros and cons of smoking.

9. The stages of change model • * Smoking processes of change scale (DiClemente and Prochaska 1985), which measures an individual's stage of change. According to this scale, the subjects were defined as precontemplators (n = 166), contemplators (n = 794) or as being in the preparation stage (n = 506). • * Demographic data, including age, gender, education and smoking history.

10. The stages of change model • At baseline the results showed that those in the preparation stage smoked less, were less addicted, had higher self-efficacy, rated the pros of smoking as less and the costs of smoking as more, and had attempted to quit more often than the other two groups. At both 1 and 6 months, the subjects in the preparation stage had attempted to quit more often and were more likely not to be smoking.

11. Interventions to promote cessation • Interventions to promote cessation can be described as: • (1) clinical interventions, which are aimed at the individual, • (2) self-help movements • (3) public health interventions, which are aimed at populations.

12. Clinical interventions: promoting individual change • Disease perspectives on cessation • Nicotine fading procedures encourage smokers gradually to switch to brands of low nicotine cigarettes and gradually to smoke fewer cigarettes.

13. Clinical interventions: promoting individual change • It is believed that when the smoker is ready to quit completely, their addiction to nicotine will be small enough to minimise any withdrawal symptoms. Although there is no evidence to support the effectiveness of nicotine fading on its own, it has been shown to be useful alongside other methods such as relapse prevention (e.g. Brown et al. 1984). But other evidence shows that people compensate by smoking more low-nicotine cigarettes.

14. Nicotine replacement. • For example, nicotine chewing gum. The chewing gum has been shown to be a useful addition to other behavioural methods, particularly in preventing short-term relapse (Killen et al. 1990). However, it tastes unpleasant and takes time to be absorbed into the bloodstream.

15. Nicotine replacement. • More recently, nicotine patches have become available and only need to be applied once a day in order to provide a steady supply of nicotine into the bloodstream. They do not need to be tasted, although it could be argued that chewing gum satisfies the oral component of smoking.

16. Nicotine replacement. • However, whether nicotine replacement procedures are actually compensating for a physiological addiction or whether they are offering a placebo effect via expecting not to need cigarettes is unclear.

17. Nicotine replacement. • Smokers are not a homogenous group. Some smokers may smoke predominantly out of habit; some due to an addiction to nicotine (Fagerstrom 1982). Accordingly, the same therapeutic approach may not be optimal for both groups.

18. Nicotine replacement. • Indeed, there is evidence that cognitive-behavioural approaches may be best for those who smoke predominantly out of habit, while nicotine replacements in combination with some form of psychological intervention may prove optimal for those with high levels of nicotine dependency.

19. Nicotine replacement. • Evidence in support of this hypothesis was provided by Hall et at. (1985), who assigned high and low nicotine-dependent smokers to either an intensive behavioural intervention, nicotine gum, or a combination of both approaches. At the one-year follow-up, 50 per cent of high nicotine-dependent smokers in the combined intervention were not smoking.

20. Nicotine replacement. • This compared with abstinence rates of 28 per cent among the equivalent group in the nicotine gum condition, and 11 per cent of those who participated in behavioural intervention. In contrast, low dependent smokers gained most from the behavioural intervention. Among this group, abstinence rates at one year were 47 per cent, in comparison to rates of 42 and 38 per cent in the nicotine gum and combined interventions.

21. Social learning perspectives on cessation • 1 Aversion therapies • aim to punish smoking rather than reward it. Early methodologies used crude techniques such as electric shocks, whereby each time an individual puffed on a cigarette or drank some alcohol they received a mild electric shock. However, this approach was found to be ineffective for smoking and drinking (e.g. Wilson 1978), the main reason being that it is difficult to transfer behaviours, which have been learnt in the laboratory to the real world.

22. Army aversion therapy for homosexuality

23. Rapid smoking • Rapid smoking is a more successful form of aversion therapy (Danaher 1977) and aims to make the actual process of smoking unpleasant. Smokers are required to sit in a closed room and take a puff every 6 seconds until it becomes so unpleasant they can't smoke anymore. Although there is some evidence to support rapid smoking as a smoking cessation technique, it has obvious side-effects, including increased blood carbon monoxide levels and heart rates.

24. focused smoking • Other aversion therapies include focused smoking, which involves smokers concentrating on all the negative experiences of smoking, and smoke holding, which involves smokers holding smoke in their mouths for a period of time and again thinking about the unpleasant sensations. Smoke holding has been shown to be more successful at promoting cessation than focused smoking and it doesn't have the side-effects of rapid smoking (Walker and Franzini 1985).

25. Contingency contracting. • Schwartz (1987) analysed a series of contingency contracting studies for smoking cessation that took place between 1967 and 1985 and concluded that this procedure seems to be successful in promoting initial cessation, but once the contract is finished, or the money returned, relapse is common.

26. Cue exposure procedures • Cue exposure procedures focus on the environmental factors that have become associated with smoking and drinking. For example, if an individual always smokes when they drink alcohol, alcohol will become a strong external cue to smoke and vice versa. Cue exposure techniques gradually expose the individual to different cues and encourage them to develop coping strategies to deal with them. This procedure aims to extinguish the response to the cues over time and is opposite to cue avoidance procedures, which encourage individuals not to go to the places where they may feel the urge to smoke.

27. Self-management procedures • Self-management procedures use a variety of behavioural techniques to promote smoking and drinking cessation in individuals and may be carried out under professional guidance. Such procedures involve self monitoring (keeping a record of own smoking/drinking behaviour), becoming aware of the causes of smoking/drinking (What makes me smoke? Where do I smoke? Where do I drink?), and becoming aware of the consequences of smoking /drinking (Does it make me feel better? What do I expect from smoking/drinking?). However, used on their own self-management techniques do not appear to be any more successful than other interventions (Hall et al. 1990).

28. Self-help movements • Although clinical and public health interventions have proliferated over the last few decades, up to 90 per cent of ex-smokers report having stopped without any formal help (Fiore et al. 1990). Lichtenstein and Glasgow (1992) reviewed the literature on self-help quitting and reported that success rates tend to be about 10-20 per cent at 1-year follow-up and 3-5 per cent for continued cessation.

29. Self-help movements • The literature suggests that lighter smokers are more likely to be successful at self quitting than heavy smokers and that minimal interventions such as follow-up telephone calls can improve the rate of success. However, although many ex-smokers report that 'I did it on my own', it is important not to discount their exposure to the multitude of health education messages received via television, radio or leaflets.

30. Public health interventions: promoting cessation among populations

31. Doctor's advice. • In a classic study carried out in five general practices in London (Russell et al. 1979), smokers visiting their GP over a 4-week period were allocated to one of four groups: • (1) follow-up only, • (2) questionnaire about their smoking behaviour and follow-up, • (3) doctor's advice to stop smoking, questionnaire about their smoking behaviour and follow-up, • (4) doctor's advice to stop smoking, leaflet giving tips on how to stop and follow-up.

32. Results at 12 months

33. Worksite interventions. • Research into the effectiveness of no-smoking policies has produced conflicting results, with some studies reporting an overall reduction in the number of cigarettes smoked for up to 12 months (e.g. Biener et al. 1989) and others suggesting that smoking outside work hours compensates for any reduced smoking in the workplace (e.g. Gomel et al. 1993). In two Australian studies, public service workers were surveyed about their attitudes to smoking bans in 44 government office buildings immediately after the ban and 6 months later.

34. Worksite interventions. • The results suggested that although immediately after the ban many smokers felt inconvenienced, these attitudes improved at 6 months with both smokers and non-smokers recognizing the benefits of the ban. However, only 2 per cent stopped smoking during this period.

35. A pilot study to examine the effects of a workplace ban on smokingon craving, stress and other behaviours (Gomel et al. 1993) • The ban was introduced on 1 August 1989 at the New South Wales Ambulance Service in Australia. This study is interesting because it included physiological measures of smoking to identify any compensatory smoking.

36. Subjects • A screening question showed that 60 per cent (n = 47) of the employees were currently smoking. Twenty-four subjects (15 males and 9 females) completed all measures. They had an average age of 34 years, had smoked on average for 11 years and smoked on average 26 cigarettes a day.

37. Design • The subjects completed a set of measures 1 week before the ban (time 1) and 1 (time 2) and 6 weeks (time 3) after.

38. Measures • At times 1, 2 and 3, the subjects were evaluated for cigarette and alcohol consumption, demographic information (e.g. age), exhaled carbon monoxide and blood cotinine (The major metabolite of nicotine that indicates levels of nicotine intake). The subjects also completed daily record cards for 5 working days and 2 non-working days, including measures of smoking, alcohol consumption, snack intake and ratings of subjective discomfort.

39. The results • The results showed a reduction in self-reports of smoking in terms of number of cigarettes smoked during a working day and the number smoked during working hours at both the 1-week and 6-week follow-ups compared with baseline, indicating that the smokers were smoking less following the ban. However, although there was an initial reduction in nicotine at week 1, by 6 weeks blood nicotine levels were almost back to baseline levels, suggesting that the smokers may have been compensating for the ban by smoking more outside the workplace.

40. The results • The results also showed reductions in craving and stress following the ban; these lower levels of stress were maintained, whereas craving gradually returned to baseline (supporting compensatory smoking). The results showed no increases in snack intake or alcohol consumption.

41. Comment • The self-report data from this study suggest that worksite bans may be an effective form of public health intervention for reducing smoking. However, the physiological data suggest that simply introducing a no smoking policy may not be sufficient, as smokers may show compensatory smoking.

42. Government interventions. • Restrictinglbanning advertising. • Increasing the cost. Research indicates a relationship between the cost of cigarettes and alcohol and their consumption.

43. Government interventions. • Banning smoking in public places. Smoking is already restricted to specific places in many countries (e.g. in the UK most public transport is no smoking). A wider ban on smoking may promote smoking-cessation. According to social learning theory, this would result in the cues to smoking (e.g. restaurants, bars) becoming eventually disassociated from smoking. However, it is possible that this would simply result in compensatory smoking in other places.

44. Government interventions. • Banning cigarette smoking and alcohol drinking. But the government loses tax and consumption is driven underground, just as drug-taking is. Also consider the unsuccessful prohibition era in the USA.

45. Methodological problems evaluating clinical andpublic health interventions • * Who has become a non-smoker? Someone who hasn't smoked in the last month/week/day? Someone who regards themselves as a non-smoker? (Smokers are notorious for under-reporting their smoking.) Does a puff of a cigarette count as smoking? Do cigars count as smoking? These questions need to be answered to assess success rates.

46. Methodological problems evaluating clinical andpublic health interventions • Should non-smokers be believed when they say they don't smoke? Methods other than self-report exist to assess smoking behaviour, such as carbon monoxide in the breath, cotinine in the saliva. These are more accurate but are time-consuming and expensive.

47. Methodological problems evaluating clinical andpublic health interventions • How should smokers be assigned to different interventions? For success rates to be calculated, comparisons need to be made between different types of intervention (e.g. aversion therapy vs cue exposure). These groups should obviously be matched for age, gender, ethnicity and smoking behaviour. Subjects could be matched on what stage of change (contemplation vs precontemptation vs preparation) they are at, or on health beliefs such as self-efficacy, or costs and benefits of smoking. The list of items to match on is endless, but it is difficult to find subjects that match if many variables to match on are used.

48. relapse rates • Although many people are successful at initially stopping smoking and changing their drinking behaviour, relapse rates are high. Interestingly, the pattern for relapse is consistent across a number of different addictive behaviours, with high rates initially tapering off over a year.

50. relapse prevention model of addictions • Marlatt and Gordon (1985) developed a relapse prevention model of addictions which specifically examined the processes involved in successful and unsuccessful cessation attempts. The relapse prevention model was based on the following concept of addictive behaviours: