Preventing and Quitting Substance abuse

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Preventing and Quitting Substance abuse

• Smoking

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DiClemente et al 1991

• A study to examine the stages of change in
  predicting smoking cessation
• 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.

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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.

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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.

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The stages of change model

• Design The subjects completed a set of measures
  at baseline and were followed up at 1 and 6
  months

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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.

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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.

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The stages of change model

• Smoking decisional balance scale (Velicer et
  al. 1985), which measures the perceived pros and
  cons of smoking.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Nicotine replacement.

• Indeed, there is evidence that cognitive-behaviour
  al 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.

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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.

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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.

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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.

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Army aversion therapy for homosexuality
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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.

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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).

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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.

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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.

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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).

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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.

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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.

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Public health interventions

• promoting cessation among populations

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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.

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Results at 12 months
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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.

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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.

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A pilot study to examine the effects of a
workplace ban on smoking on 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.

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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.

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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.

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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.

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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.

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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.

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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.

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Government interventions.

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

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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.

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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.

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Methodological problems evaluating clinical and
public 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.

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Methodological problems evaluating clinical and
public 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.

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Methodological problems evaluating clinical and
public 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.

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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.

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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

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relapse prevention model of addictions

• Addictive behaviours are learned and therefore
  can be unlearned they are reversible.
• Addictions are not 'all or nothing' but exist
  on a continuum.
• Lapses from abstinence are likely and
  acceptable.
• Believing that 'one drink-a drunk' is a
  self-fulfilling prophecy.

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relapse prevention model of addictions

• They distinguished between a lapse, which entails
  a minor slip (e.g. a cigarette, a couple of
  drinks), and a relapse, which entails a return to
  former behaviour (e.g. smoking 20 cigarettes,
  getting drunk). Marlatt and Gordon examined the
  processes involved in the progression from
  abstinence to relapse and in particular assessed
  the mechanisms which may explain the transition
  from lapse to relapse

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Aids are not being used

• Nearly 80 per cent of smokers who attempt to
  quit, do so without using any method
  ofassistance, like nicotine replacement therapy
  orcounselling. Yet research shows that smokers
  who use aids are twice as likely to achieve
  long-term abstinence from smoking. David
  Hammond(University of Waterloo, Ontario) and
  colleagues interviewed 616 adult smokers over the
  telephone to investigate why so few smokers use
  available aids to help them stop smoking.

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Aids are not being used

• It could be because they don't know about the
  available aids. Indeed, when asked to"list as
  many different methods...for quitting smoking as
  you can", a third ofHammond's sample failed to
  mention nicotine replacement therapies, and only
  halfmentioned Zyban, an antidepressant known to
  help people quit. At the same time, a quarter of
  participants mentioned an aid to stoppingsmoking
  for which there's no evidence of effectiveness,
  like hypnosis or acupuncture.

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Aids are not being used

• There was also evidence that smokers don't
  believe available aids are effective.Nearly 80
  per cent said they thought they would be as
  successful quitting on their own, as with help.

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Aids are not being used

• And failing to recognise the effectiveness of
  'quitting aids' could be underminingsmokers'
  attempts to stop. Three months after the initial
  telephone survey, thoseparticipants who had
  rated 'quitting aids' as effective, were twice as
  likely to havesince made an attempt to quit.

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The End