Monday, September 18, 2006
Friday, September 01, 2006
Evaluation Points You Should Know For Substance Use and Abuse
2) Methodological problems evaluating clinical and public health interventions to prevent smoking addiction.
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.
Who is still counted as a smoker? Someone who has attended all clinic sessions and still smokes? Someone who dropped out of the sessions half-way through and hasn't been seen since? Someone who was asked to attend but never turned up? These questions need to be answered to derive a baseline number for the success rate.
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 and cotinine in the saliva. These are more accurate but are time-consuming and expensive.
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. Ps 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 Ps that match if many variables to match on are used.
3) The social dimension is missing from many of the popular explanations of addiction. This is obviously important because of the significant positive correlation between lower socioeconomic groups and addiction to illegal and health damaging substances. Thus many current explanations would seem to reduce addiction to either biological or psychological levels and ignore the complexity of the issues when an interactionist approach is adopted which would look at how biology, psychology and social factors interact to create addiction.
4) Problems with the Disease Model. There are some problems with the disease model, the main one being that the nature of the disease has never been identified. What sort of disease is it, and how can a disease make people take drugs? There have been a number of attempts to explain the abuse of specific drugs in terms of a disease process; for example, it has been suggested that alcoholism is a result of a type of food allergy to the grain from which alcohol is manufactured, but such attempts have been limited to a specific drug and have never been particularly convincing.
There has never been a comprehensive disease theory that suggests a mechanism that can account for all types of addictions as a single disease, Perhaps this is not necessary, but considering the similarity of different addictions, it would be scientifically pleasing, and much more useful, if one theory could explain many different addictions. The continued absence of any disease mechanism that can account for the compulsive use of specific drugs or addictive behavior in general makes it increasingly difficult to accept the belief that addiction is a pathological condition.
There are those who argue that the fact that we do not understand the origins or the mechanism of the disease does not mean it is not a disease (Maltzman, 1994). In fact, we recognized many conditions such as diabetes and polio long before science could explain them in terms of biochemical deficiencies or viruses. Nevertheless, one might expect after all this time that some sort of disease process would have been discovered that would explain the compulsive use of at least one drug.
Defining Substance Use and Abuse
What is a drug?
There are various elements to this question, as the concept is heavily influenced by both the socio-cultural context and the purpose of its use. The definition of the term drug is a product of social custom and law, both of which change over time (Smith 1970). According to the World Health Organization (1981), a drug is defined as
'any chemical entity or mixture of entities, other than those required for the maintenance of normal health (like food), the administration of which alters biological function and possibly structure'
A drug, in the broadest sense, is a chemical substance which has an effect on bodily systems and behaviour. Drugs can be therapeutic, non therapeutic or both. A psychoactive drug is a drug that affects the central nervous system and alters mood, thinking, perception and behaviour. In this context, alcohol, tobacco and drugs (prescribed and illicit) are psychoactive substances. It is these drugs that psychologists are mostly concerned with. Though it is worth noting that the issue of substance abuse can also cover food, solvents, etc. Indeed anything that would be refered to as a substance and ingested into the body in some fashion can be abused and therefore of interest to psychologists.
According to the World Health Organisation (WHO) there are 4 basic forms of drug use -
- Unsanctioned use: a drug that is not approved by society.
- Hazardous use: a drug leading to harm or dysfunction.
- Dysfunctional use: a drug leading to impaired psychological or social functioning.
- Harmful use: a drug that is known to cause tissue damage or psychiatric disorders.
What is substance use and abuse?
The terms substance use and abuse are difficult concepts to define precisely. The operational use of these concepts is heavily dependent on particular ideology and clinical practice. Substance use can be defined as the ingestion of a substance which is used for therapeutic purposes or as prescribed by medical practitioners. Substance misuse is the result of a psychoactive substance being consumed in a way that it was not intended and which may cause physical, social and psychological harm. It is also used to represent the pattern of use: experimental, recreational and dependent. (Rasooll, 1998).
According to Rasool (1998) the term substance abuse, which is often associated with addiction and dependence, is considered to be value laden and has limited use in the addiction literature in the UK. In the USA, practitioners prefer the term substance abuse for problems resulting from the use of alcohol or other mood altering drugs and use addictive disorders when the problems have escalated to dependency (Sullivan 1995). Whether a substance is used or abused depends very much on the social and cultural context, the individual perspective, the pattern and mode of consumption and the perception of the observer.
The Advisory Council for the Misuse of Drugs (ACMD) prefers the term 'problem drug user, which they define as -
'any person who experiences social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of his own use of drugs or other chemical substances.'
The above definition focuses on the needs and problems of the individual and places less emphasis on the substance oriented approach. It is a holistic definition in acknowledging that the problem drug user has social, psychological, physical and legal needs and the definition could be expanded to incorporate the spiritual needs of the problem drug user.
What is addiction?
A related concept to these issues is that of addiction. Addictive behaviour is a complex dynamic behaviour pattern having psychological, physical, social and behavioural components. Addictive behaviour, according to Marlatt et al. (1988) is defined as
'a repetitive habit pattern that increases the risk of diseases and/or associated personal or social problems. The individual usually has a loss of control, immediate gratification with delayed, deleterious effects, and experiences relapses when trying to quit.'
Using this type of definition one can understand that, from a psychological persepctive, any substance could be a component of addiction, for example, chocolate!
However when discussing drug addiction, rather than any other substance, or indeed behaviours, it is useful to know what we are specifically refering to. One way to refer to, and to think about, drug addiction is to use the term of drug dependence. The World Health Organisation (WHO) in 1969, defined drug dependence as -
'a state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug, characterised by behavioural and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its physical effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug.'
This comprehensive definition has been widely accepted and highlights the core features of dependence such as tolerance and psychological and physical dependence -
1. According to Rassool (1998), tolerance is a behavioural state and refers to the way the body usually adapts to the repeated presence of a drug. Higher doses of the psychoactive substance are required to reproduce the original or similar effects. The drug must be taken on a regular basis and in adequate quantities for tolerance to occur. Tolerance can be subdivided into:
- Pharmacodynamic tolerance, when higher doses of the drug are needed to produce the desired response or effect.
- Metabolic tolerance, when there is an increased capacity to metabolise a drug.
- Cross tolerance - when one is tolerant to one drug, there is also tolerance to other drugs of the same type or classification.
2. Psychological dependence can be described as a compulsion or a craving to continue to take a drug because of the need for stimulation, or because it relieves anxiety or depression. Psychological dependence is recognised as the most widespread and the most important (ISDD 1996). This kind of dependence is not only attributed to the use of psychoactive drugs but also to food, sex, gambling, relationships and physical activities. (Rassool, 1998)
3. Physical dependence is a state of bodily adaptation to the presence of a particular psychoactive drug. This manifests itself in physical disturbances or withdrawal symptoms following cessation of use. The withdrawal symptoms depend on the type or category of drug. For example, for nicotine, the physiological withdrawal symptoms may be relatively slight. In other dependence inducing psychoactive substances, such as opiates and depressants, the withdrawal experience can range from mild to severe. Physical withdrawal syndromes are not, however, the essence of dependence. It is possible to have dependence without withdrawal and withdrawal without dependence (Royal College of Psychiatrists, 1987). However, it is argued that many of the supposed signs of physical dependence are sometimes psychosomatic reactions triggered off, not by the chemical properties of the psychoactive drug, but by the user's fears, beliefs and fantasies about what withdrawal entails (Plant 1987).
Patterns of substance use and abuse
The patterns of drug or alcohol use and misuse for some individuals may vary over a period of time. According to Rassool (1998) substance misusers are often described as experimental, recreational and problematic -
Experimental users are described as those who use drugs, legal or illicit, on a few occasions By definition, anyone's initial use of a drug is experi- mental. The main motivation for experimental drug or alcohol use includes curiosity, anticipation of effects and availability. There is no pattern in the use of psychoactive substances but the choice of the drug misused is indiscriminate. The choice of drug use depends on factors such as availability, reputation of the drug, subculture, fashion and peer group influence. Experimental use of illicit psychoactive substances is usually a short lived experience and the majority of people may confine the consumption to drugs that are socially acceptable. Experimental users, however, are in the highest category of risk for infections (if injecting), medical complications or overdose due to the indiscriminate use of adulterated psychoactive substances.
Experimental users may or may not become recreational users of illicit psychoactive substances. The term recreational refers to a form of substance use in which pleasure and relaxation are the prime motivations. There is a strict adherence to the pattern of use so that the drug is only used on certain occasions, such as weekends, and less likely on consecutive days. There is usually a preference for a particular drug (drug of choice) - the user has leamt how to use it and appreciate its effects. Drug or alcohol use is one aspect of the user's life and tends to complement social and recreational activities.
By definition, a dependent user has progressed to regular and problematic use of a psychoactive drug or has become a polydrug user. There is the presence of psychological and/or physical dependence and it may be distinguished from experimental and recreational use. The pattern of use is more frequent and regular but less controlled. The process of obtaining the drug is more important to the user than the quality of the experience. This tends to displace rather than complement social activities.
Theories of Substance Abuse; for Smoking Tobacco
Before looking at explanations for why people smoke, it is useful to know about some of the more general explanations that are offered for substance abuse. These can be summarised as -
The Moral Model
According to this model individuals are viewed as responsible for the initiation and development of problems as a result of substance misuse. Addictive behaviours such as drug taking, heavy drinking or gambling are seen as sinful or weak willed. Substance misusers need to exert willpower to refrain from drinking or taking drugs and treatment consists of mainly spiritual intervention.
The Medical/Disease Model
This model views addictive behaviour as a progressive, incurable disorder and the cause of the disease is firmly attributed to the genetic/biological make up of the individual. This medical/disease approach also implies the adoption of the sick role by the substance misusers and the individuals are expected to be treated as having a 'disease'. The treatment approach also implies that recovery from drug or alcohol misuse can only be sustained through the goal of total abstinence.
The Psychological Model
The psychological model includes the social learning, family interaction and personality approaches. The social learning theory model proposes that social behaviour is learnt through observation and modelling. It is stated that modelling by parents is an important factor in the initial pattern of consumption of social and illicit psychoactive substances, especially in those with poor social skills (Baer et al. 1987). The family interaction model emphasises the role of parental behaviour in the abuse of substances, especially in the case of alcoholism. The personality characteristics of the substance misuser have also been linked to substance misuse. Several factors, including lack of maturity, interpersonal and intrapersonal conflicts, low self-esteem, underlying depression and anxiety, inability to cope with anger, etc., have been suggested to be the cause of drug and alcohol problems. The term 'addictive personality' has been ascribed to those individuals who have become dependent on drugs or alcohol. (Rassool, 1998)
The Sociocultural Model
Sociocultural explanations of the use and misuse of psychoactive substances emphasise the role of culture, beliefs, values and attitudes held by a community or minority groups in the way individuals will abstain from or take drugs. Cultural attitudes towards the use of psychoactive drugs may also play an important part in shaping individual behaviour. Sociological factors such as unemployment, social deprivation, poor environment, etc., may have important effects on whether individuals start misuse drugs and whether they continue (Peck & Plant 1986). Other social factors such as age, sex, religion, ethnicity, socio-economic class and family background directly influence whether an individual will use psychoactive substances in that way.
Explanations for why people smoke tobacco -
Biological theories of smoking
Nicotine, the main active ingredient in tobacco smoke, is a substance which if taken in large quantities can be toxic. However, delivered in small amounts via cigarette smoke it has a range of psychophysiological effects including tranquillization, weight loss, decreased irritability, increased alertness and improved cognitive functioning (Rose, 1996). The apparent conflict between the stimulant physiological effect of nicotine and reports of relaxation has been called the 'nicotine paradox' (Nesbitt, 1973). One explanation for this paradox is that smoking appears relaxing because the smokers are often in a state of mild nicotine withdrawal which is relieved by the cigarette which returns the nicotine level in the body to 'normal' (Hughes, 1991; Foulds and Ghodse, 1995).
Over time the smoker seems to develop a physical dependence on nicotine. In the USA several tobacco companies have publicly admitted that smoking is addictive. In 1997 the smallest of the big five US tobacco companies (the Liggett Group) admitted that it had raised the nicotine content in cigarettes to increase their addictiveness (Porter, 1997). The USA Department of Health and Human Services (1988) reported that 'the pharmacologic and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine'.
The experimental work of Schachter et al (1984) developed the nicotine regulation model of smoking. According to this model there is a physiological regulatory mechanism which monitors the level of nicotine in the brain. When this falls below a certain level the individual feels the need for another cigarette.
Admittedly, not all people smoke or exhibit a desire to smoke. This raises the suggestion that perhaps there is a genetic component. A number of twin studies from different continents have produced evidence of strong genetic link in the risk of smoking. Heath and Madden (1995) reviewed the evidence from national twin studies in Scandinavia and Australia. In their predictive model genetic factors increased both the likelihood of becoming a regular smoker ('initiation') and of these smokers becoming long-term smokers ('persistence'). In a large follow-up survey of the smoking practices of male twin pairs from the US Vietnam Era Twin Registry, True et al. (1997) found that genetic factors accounted for 50% of the risk of smoking and environmental factors accounted for a further 30%. In addition, genetic factors accounted for 70% of the risk variance of becoming a ereas environmental factors were not important.
Psychological theories of smoking
Probably the most frequently used model of smoking is that based on learning theory. Basically, it argues that people become smokers because of the positive reinforcement they obtain. Initially, smoking is physically unpleasant but this is overruled because of the social reinforcement from peers. The pleasant associations of smoking then generalize to a range of other settings. In addition, the smoker learns to discriminate between those situations in which smoking is rewarded and those in which it is punished. He or she also develops responses to a number of conditioned stimuli (both internal and external) which elicit smoking. Smoking can be conceptualized as an escape/avoidance response to certain aversive states (Pomerlau, 1979). The smoker will light up a cigarette to escape or avoid an uncomfortable situation.
Part of the above explanation canbe highlighted by a study conducted by Murray et al (1988) asked young adults to indicate what factors were important reasons for smoking in different situations. In all situations relaxation and control of negative affect (emotional states)were considered the most important reasons. At home boredom was also considered important, perhaps reflecting these young people's frustration with family life. At work addiction was considered important, perhaps reflecting the extent to which it disrupted their work routine, while socially habit was rated important.
There may also be personality differences between smokers and non-smokers. According to Zuckerman (1979) individuals engage in sensation seeking so as to maintain a certain level of physiological arousal. Carton et al. (1994) found in a French sample that smokers scored higher on a measure of sensation seeking, in particular on disinhibition, experience seeking and boredom susceptibility subscales. They suggest that from a physiological perspective these sensation seekers have a low level of arousal and seek exciting, novel or intense stimulation to raise their level of cortical arousal. This argument is very similar to that of Eysenck et al (1960) who found that smokers scored higher on measures of extroversion. This personality dimension is also supposed to reflect a lower level of cortical arousal which could be raised by engaging in risky activities such as smoking.
Lastly, a variety of different types of studies have found that stress is associated with smoking. Schachter et al. (1984) found that among smokers, consumption was higher in experimental stressful laboratory situations. Lindenthal et al. (1972) found in a survey that people with higher selfreports of stress were more likely to be heavy smokers. In a study of nurses' smoking practices, Murray et al. (1983) found that those who reported the most stress were more likely to smoke. This relationship remained after controlling for the effect of family and friends' smoking practices.
Social theories of smoking
Smoking is a social activity, thus social factors may contribute to why some people become addicted to smoking. Even when the smoker smokes alone he or she society where cigarettes are widely available and promoted. A number of qualitative studies have considered the social meaning of smoking to highlight the point that there is more to smoking addiction than biological and psychological aspects. For example, Murray et al (1988) conducted detailed interviews with a sample of young adults from the English Midlands. These suggested that smoking had different meanings in different settings. For example, at work going for a cigarette provided an opportunity to escape from the everyday routine. As one young factory worker said:
'We would say we were going to the toilet and have a quick cigarette ... As long as they [management] didn't catch you. If they caught you, well, you'd be in hing. But it was alright. We used to go in about every hour, something like that.' (Murray et al., p. 49)
For these workers, to have a cigarette meant to have a break and conversely not to have a cigarette meant not to have a break. The cigarette was a marker, a means to regulating their work routine.
Outside work, smoking was perceived as a means of reaffirming social relationships. For those young people who went to the pub, the sharing of cigarettes was a means of initiating, maintaining and strengthening social ire cigarettes were frowned upon. One young man explained when he smoked:
'Only, basically, when somebody else has one. Say we're all out in a group, say, ig [sharing] the fags [cigarettes] and that. Say it's somebody else's turn, I'd wait for them to get one out. I wouldn't light one of my own. I'd wait for him to get his out and if it's my turn, I'd just wait about ten minutes and get mine out ... I can't handle that, people who just smoke on their own. It doesn't seem right.' (Murray et al 1988, p. 65)
In another series of studies, along similar lines, Graham (1976,1987) provided a detailed understanding of the meaning of smoking to working-class women. In one of her studies (Graham, 1987) she asked a group of low-income mothers to complete a 24-hour diary detailing their everyday activities. Like the young workers in the study by Murray et al. (1988), smoking was used as a means of organizing these women's daily routine. For example, one woman said:
'I smoke when I'm sitting down, having a cup of coffee. It's part and parcel of resting Definitely, because it doesn't bother me if I haven't got a cigarette when I'm working. If I'm busy, it doesn't bother me, but it's nice to sit down afterwards and have a cigarette.' (Graham, 1987, p. 52)
Further, for these women smoking was not just a means of resting after completing certain household tasks but also a means of coping when there was a sort of breakdown in normal household routines. This was especially apparent when the demands of childcare became excessive. Graham describes smoking as 'not simply a way of structuring caring: it is also part of the way smokers re-impose structure when it breaks down' (p. 54). She gives the example of one woman who said:
'If it's nice, I send them [children] out or ask them to play in the bedroom but normally I will sit in the kitchen and have a cup of coffee and a cigarette . . . The cup of coffee calms me best, then a cigarette and then it's just being on my own for a few minutes to sort of count to ten and start again.' (Graham, 1987, p. 54)
Graham (1987) argues that for these women smoking is an essential means of coping with everyday difficulties. It is also a link to an adult consumer society. Through smoking the women were reaffirming their adult identity.
Preventing and Quitting Substance Abuse; for Smoking
Biological aspects of cessation (stopping).
It is well established that cessation of smoking by regular smokers leads to a variety of symptoms such as irritability, difficulty concentrating, anxiety, restlessness, increased hunger, depressed mood and a craving for tobacco Stolerman & Jarvis, 1995). Important evidence that these withdrawal symptoms are due to the loss of nicotine is the finding that it is relieved by administration of nicotine but not of a placebo (Jarvis et al., 1982).
This evidence has led to the development of a variety of pharmacological productsaimed at aiding smoking cessation. These are designed to deliver nicotine directly rather than through cigarette smoke. The techniques developed include nicotine chewing gum, nicotine transdermal patch and a nasal spray or inhaler. Evidence from clinical trials has demonstrated that these techniques are effective (Stolerman and Jarvis, 1995). However, the individual smoker must still have the psychological motivation to use them.
Psychological aspects of cessation (sourced from Marks et al, 2000)
One theraputic intervention that is popular amongst psychologists is cognitive behavioural therapy (CBT). An example of a brief intervention using CBT is the QUIT FOR LIFE (QFL) Programme developed by Marks (1993). This encourages a steady reduction of cigarette consumption over seven to ten days followed by complete abstinence. The QFL programme is delivered in several alternative ways: as a group therapy of 10 sessions, as a self-help programme following a single, one-hour group therapy session, or on the internet. The programme uses a spectrum of 30 cessation methods in a self-help package. QFL requires a gradual reduction of cigarette consumption over a period of seven to ten days. A set of targets is used, directed towards a 50% reduction each day. Of particular importance is the objective of increasing the smoker's confidence or self-efficacy that he/she will be able successfully to make ange from smoker to non-smoker. The attempt to increase self-efficacy is a persistent and unflagging component of the therapy. It is essential that the therapist is constantly vigilant concerning the smokers' ever more creative rationalizations as they proceed towards their 'D-Day', the first 24-hour period when they are not expected to smoke at all.
One aspect of the course requires the P to imagine that the brain is a sophisticated biological computer, or 'biocomputer', consisting of the central nervous system (or hardware) and learned 'programs' (or software) which enable the nervous system to process information. In order to quit smoking, it is suggested that the smoker must alter the software or 'programming' which currently dictates that the smoking must occur in a fixed and uncontrollable way. Following the computer metaphor, it is necessary for the smoker to eliminate his/her pro-smoking software and to restore non-smoking software. This requires a period of systematic re-programming, achieved by systematic repetition during the act of smoking when pro-smoking 'programs' are replaced by new, anti-smoking 'programs'. The smoker repeats a four-line 'program', coded by the mnemonic NURD (smoking offers me No satisfaction, is Unpleasant, makes me feel Rotten, I am losing the Desire to smoke), while actively smoking a cigarette. As the 'program' is repeated over and over while engaged in smoking activity, the pleasure of smoking and desire to smoke are expected to diminish. This technique is one of 30 methods within QFL and is not expected to be sufficient on its own.
The QFL Programme is divided into two stages, reduction and relapse prevention. It is further subdivided into 10 sections spaced across a period of three months. The reduction stage begins on a Tuesday and finishes on the following Monday, Tuesday, Wednesday or Thursday with D-Day. Relapse prevention begins immediately after D-Day and continues formally for 12 weeks. This stage incorporates an element of nicotine replacement therapy (NRT) during a period of 10-30 days immediately following D-Day when smokers may use a low dosage level gum or patch.
Marks and Sykes (1999): In this study 260 participants were recruited from the North London population and randomly allocated to one of the two treatment conditions (QFL or control). Outcome measures consisted of point abstinence rates and reduction scores at three, six and 12 months. The abstinence and reduction data were validated using breath carbon monoxide readings. The 12-month follow-up revealed that 23 of 116 (19.8%) QFL participants were abstinent, compared to six of the 104 (5.8%) contactable control participants. Ten (8.6%) of the QFL group but none of the control group reported a reduced consumption. Approximately one in four (33/116 or 28%) of participants were abstinent or had a significantly lower cigarette consumption 12 months after the treatment compared to one in 17 (6/104 or 5.8%) of the controls.
Social aspects of cessation
Rather than using an individualised approach to quitting smoking an alternative is to use small groupings of smokers who are all ready to give up. Mills (in Marks et al, 2000) outlines one approach to group treatment. The key points are -
- Assess Ps nicotine dependence and motivation to quit.
- Assess patient's suitability for group therapy.
- Arrange venue and time and question whether the patient is able toattend all sessions.
- Send postal reminders to those accepted for group treatment including a map and directions to the venue. Reiterate the quit date and the importance of commitment.
- Two group therapists are necessary - one to lead the sessions, the other to provide emergency cover for sickness and to assist, particularly at the start of each session, when ECO (expired carbon monoxide) levels are measured.
Once the ground rules are described the group therapist should not take a major role in leading the group. Other group members should be encouraged to use their own expertise in supporting each other. In this way the group maintains both support and pressure for each other to maintain abstinence, helping to pull along those members who may be weakening in their resolve to quit (Hajek 1994). By allowing the group to form us uw alliances this should ensure that the 'classroom' situation does not prevail. The role of the therapist should be to encourage goal focused discussion among members of the group while maintaining a 'low profile', and to facilitate group discussion rather than provide answers at every opportunity (Hajek, 1994).
In session one each member identifies themselves and gives a brief outline of their smoking history. In subsequent sessions, they report whether they have been abstinent and outline how the week has progressed with regard to withdrawal discomfort, craving to smoke and stressful situations which they have overcome. Longer discussion then follows where group interaction reinforces their commitment, particularly amongst those who may be finding it difficult to stay abstinent. During session five (the last session), group members who have remained abstinent from week one or at least during the past week (as confirmed by their ECO reading) receive a certificate which states the date when they stopped smoking. Although this is generally accepted as a 'fun ceremony', the certificates are particularly prized by some members as a reflection of the effort expended, and many say they will have it framed and displayed rominently as a reminder of this. Instruction and advice on the connuation of NRT is offered and members are encouraged to contact a smokers' clinic for help or advice in the future. The session ends with members making a commitment to remain non smokers.