Tobacco cessation strategies and effectiveness

Tobacco Cessation Treatment Plan

This project consists of a plan designed to help a patient stop smoking. Interviews with the patient indicate that the patient has tried to quit smoking several times unsuccessfully and that two specific barriers have emerged as obstacles in prior attempts: (1) Behavioral Cues and Patterns, and (2) Physiological Cravings (i.e. nicotine withdrawal symptoms). In principle, this project is designed to separate those two issues and to enable the patient to separately address the factors associated with those two different sets of obstacles.

Patient Evaluation

The patient is 37 years old and has been smoking since the age of 16. She reports having tried to quit several times unsuccessfully; the longest period of cessation was approximately 60 days. The patient understands the long-term negative health consequences associated with smoking and reports having experienced numerous symptoms such as shortness of breath and bronchitis and has expressed significant frustration over being unable to stop smoking despite genuinely wanting to quit. She is generally in good health but exhibits typical respiratory function deterioration consistent with her smoking history.

Specific Questions Asked

1. How long have you smoked?

2. Have you tried to quit and if so, approximately how many times?

3. What was the longest period of time that you ceased smoking?

4. Please describe the circumstances that you believed caused you to fail?

5. Please describe how intensely you experienced nicotine cravings.

6. Please describe how intensely you experienced external temptations.

7. How committed are you to following a smoking cessation program?

Treatment Plan Development

Because the patient describes two specific types of barriers to the success of her prior smoking cessation attempts, this treatment plan focuses on each of those barriers separately. More specifically, this treatment plan will consist of an entirely different approach to those two types of barriers. In that regard, physiological symptoms of nicotine withdrawal will be addressed in a manner consistent with classical understanding of physical manifestations of substance addiction emphasizing gradual reduction of dosage.

The physical addiction-based component of this treatment plan will consist of allowing the patient to self-administer the smallest doses of nicotine to reduce acute symptoms of nicotine withdrawal. In the early phases of the program, the patient will be allowed to smoke a limited number of cigarettes as necessary to treat acute physical symptoms of nicotine withdrawal. In the latter stages, this treatment plan calls for the transition from smoking cigarettes for that limited purpose to other forms of nicotine administration such as trans-dermal patches and orally-administered nicotine.

The behavior-based component of this treatment plan will consist of educating the patient to understand the behavioral cues responsible for undermining her previous smoking cessation attempts. A large aspect of that objective will involve educating the patient to recognize and distinguish bona-fide signs of physical addiction and nicotine withdrawal from smoking impulses attributable to behavioral cues and other non-physical triggers. The patient will be prohibited from smoking anytime the impulse is a function of behavioral cues and triggers not directly attributable to acute physical symptoms of nicotine withdrawal.

There will also be a behavioral aspect to the physical addiction-based component of this treatment plan. Specifically, this program requires the patient to completely dissociate any elements of ritual, comfort, of socializing that have previously been associated with her smoking. The strategy for this component will consist of a commitment never to smoke in any circumstance where it is enjoyable or relaxing or part of any social ritual. In addition, the limited amount of smoking authorized for the sole purpose of addressing actual nicotine withdrawal symptoms will required to be combined with some element of discomfort to further reduce any positive behavioral association.

For example, the patient will be expressly forbidden from smoking based on behavioral cues or previous patterns such as immediately upon waking, with coffee, after meals, in conjunction with social interactions, or while doing anything enjoyable or recreational such as watching television. The purpose is to ensure that the only time the patient smokes during the first phase of this treatment plan will be for the express purpose of administering the necessary "dose" of nicotine to address actual physical withdrawal symptoms.

To help ensure that the only smoking will be for the purpose of addressing symptoms of physical withdrawal in the manner intended, the patient will be required to agree to conditions under which permissible smoking will occur. For example, if she determines that smoking is necessary because of actual symptoms of physical withdrawal, she will smoke a half of one cigarette standing on one leg in her backyard, or while standing and balancing a textbook on her head, or in other comparable mildly uncomfortable circumstances that remove any aspect of relaxation or enjoyment. The patient will not be allowed to smoke while sitting comfortably, while simultaneously talking on the phone, or in the company of others, especially other smokers.

Addressing Anticipated Issues

It is anticipated that the patient will initially have some difficulty recognizing and distinguishing behavioral motivations for smoking and physical cravings or bona-fide withdrawal symptoms. Those issues will be addressed by helping the patient understand and identify the factors associated with behavioral triggers that are not legitimately functions of physical withdrawal symptoms. It is also anticipated that the patient will be more reluctant to give up certain so-called "comfort" cigarettes or smoking in social situations. The practitioner will address those potential barriers by impressing on the patient that the only legitimate "excuse" for smoking during this smoking cessation program is that which is necessary to resolve actual symptoms of physical withdrawal and that failure to eliminate all other smoking is inconsistent with any possibility of success. Finally, it is anticipated that the patient may be legitimately confused by situations where both behavioral triggers and physical withdrawal symptoms exist concurrently. The practitioner will reinforce the significance of eliminating any aspect of comfort or enjoyment associated with smoking precisely for that purpose.