Dual-approach tobacco cessation plan addressing behavioral and physiological barriers

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.

Incorporating Patient Management Skills and Providing Follow-up

The practitioner expects that the patient will have some difficulty making a good-faith distinction between behavioral triggers and physical withdrawal symptoms. Patient management and follow-up care will focus on that issue. Likewise, the practitioner expects that the patient will report difficulty religiously avoiding social smoking situations or adhering strictly to the prescribed circumstances of permissible smoking. Patient management and follow-up in that regard will consist of educating the patient about the fundamental importance of adhering to the parameters of the program if she is to be successful in her goal. Therefore, she will be counseled to avoid placing herself in social situations where she is unable or unwilling to forego sharing smoking breaks with others. With respect to adhering to the mechanisms designed to make smoking at home slightly unpleasant, the practitioner will assist the patient devise appropriate criteria that fulfill their purpose in ways to which she can adhere without deviation.

Ultimately, the goal of patient follow-up will be to help the patient completely eliminate all smoking other than that necessary to address actual physical symptoms of nicotine withdrawal so that she can transition to the final phase of substituting smoking with other forms of nicotine administration in conjunction with a schedule for eventually reducing and eliminating that form of nicotine consumption as well.