Substance use and abuse

Friday, September 01, 2006

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.


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