Cigarette Smoking

Cigarette smoking is a behavioral risk factor for disease and one that is amenable to intervention by counseling psychologists. Clients who seek help for emotional and behavioral problems are more likely than others to be cigarette smokers, and counseling psychologists should become familiar with treatment guidelines that exist. All smokers should be encouraged to quit, and brief interventions are effective for motivating smokers to consider quitting. More intensive treatment has been shown to be effective, but such intervention may require specialized training. Smoking is a chronic condition, and relapse is common. This entry provides statistics and information about smoking as well as guidelines for counseling the smoker.

Cigarette Smoking Statistics

Cigarette smoking increases risk for disease, and cessation can reverse this risk. It is estimated that male smokers lose an average of 13.2 years of life and female smokers lose 14.5 years due to smoking. However, cessation can minimize these health risks. Individuals who stop smoking before age 35 avoid 90% of the risks associated with cigarette smoking.

The percentage of people who smoke cigarettes in the United States has declined from highs in the mid-1970s of 42% to approximately 28% today. Trends suggest that there is a deceleration in this decline. There are also some indications that there may be a slight increase in tobacco use among teens and college students. Data from the Monitoring the Future Study conducted at the University of Michigan suggest that in 2005, 1 in 11 eighth graders and 1 in 4 twelfth graders had smoked in the past 30 days. While these rates are lower than in the past, they remain at an unacceptably high level.

Hazards of Cigarette Smoking

The harmful effects of cigarette smoking are well documented, and today there is a growing understanding of the harmful effects of involuntary exposure to tobacco smoke in the environment. In June of 2006, the surgeon general issued a report documenting the harmful health effects of exposure to tobacco smoke and urged greater attention to this problem. Data from this report indicate that approximately 60% of non-smokers in the United States show biological markers indicative of environmental exposure to tobacco smoke. It is likely that there will be even greater attention given to this aspect of cigarette smoking in the coming years, and there will be policy changes such as the implementation of smoke-free workplaces.

Similar policies are currently being implemented in many healthcare facilities.

Etiology of Tobacco Dependence

Cigarette smoking typically results in nicotine dependence and nicotine withdrawal, two Axis I disorders classified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Compared to other drugs of abuse, such as marijuana, cocaine, or alcohol, tobacco is more likely to cause dependence. Recent studies have documented that more than 80% of individuals who report regular smoking meet criteria for nicotine dependence. Likewise, 32% of all individuals who have ever tried any tobacco products progress to nicotine dependence. Comparable statistics for heroin, cocaine, and alcohol are 23%, 17%, and 15%, respectively. Tobacco has a high risk for dependency.

Cigarette smoking is commonplace among psychiatric patients. There are differing perspectives as to why psychiatric patients smoke. Some have suggested that smoking is an attempt to self-medicate emotional symptoms. Research indicates that stress exacerbates urges or cravings to smoke and is associated with relapse. In addition to an association with emotional problems, cigarette smoking is clearly associated with other substance use problems, including use of alcohol, caffeine, and illegal drugs. The more severe the emotional disorder, the more likely that smoking will be present and the greater likelihood of dependence. Additionally, cessation is likely to be more difficult with severe emotional disorders.

Cigarette Smoking Cessation

Clinical practice guidelines for working with smokers were developed by the United States Public Health Service in 1996 and revised in 2000. The goal of these guidelines is to provide health care providers with evidence-based recommendations regarding methods for increasing the likelihood of successful smoking cessation. Counseling psychologists, as healthcare professionals, should consider adopting these guidelines with all clients regardless of presenting problems. The guidelines allow for client autonomy while maximizing effectiveness for clients who desire help.

Assessment of Tobacco Use

For clients who do not want to quit smoking, it is suggested that a brief intervention be provided to help increase motivation to quit. Clients who want to quit should be provided with assistance using effective strategies. Details can be found in the monograph Treating Tobacco Use and Dependence (Fiore et al., 2000), which can be downloaded from the Web.

Healthcare providers should assess the smoking status of every client at every visit. For individuals who smoke, it is recommended that one assess the client’s interest in stopping. Depending on the answer to questions regarding desire to quit, a brief motivational intervention is recommended that can enhance motivation to quit for individuals who are not ready to quit and can be the first step in cessation for individuals ready for cessation.

Role for Counseling Psychology in Smoking Cessation

While the clinical practice guidelines have been in place since the mid 1990s, most studies suggest that healthcare providers do not use the guidelines. For example, physicians frequently fail to counsel clients to quit smoking, although there is some evidence that rates of physician assistance are increasing, and one study showed that over 50% of physicians advised smokers to quit. Most other healthcare professionals (pharmacists, public health nurses, chiropractors, and dentists) use these guidelines less often than physicians. A recent survey of licensed psychologists indicated that psychologists often provide assistance and intervention for clients who want to quit smoking, but like other healthcare providers, they rarely inquire about a client’s tobacco use.

Given that psychologists are often in a position to provide effective intensive clinical interventions for smoking cessation or at least to provide brief interventions, it is disappointing that as a health care profession, psychologists are not leading the way. This is particularly important given the high comorbidity seen for cigarette smoking and other mental health problems. As noted earlier, smoking rates are substantially higher for individuals with psychiatric mood, anxiety, and psychotic problems, and these individuals have more difficulty with cessation than individuals without comorbid psychological problems.

Recently, Miles McFall and his colleagues at the Seattle Veterans Administration Medical Center have initiated smoking cessation treatment for patients seeking treatment for posttraumatic stress disorder (PTSD). His data suggest that clients who received integrative treatment (e.g., treatment for both PTSD and cigarette smoking) were 5 times more likely to abstain from smoking than those who received standard PTSD treatment. More importantly, stopping smoking was not associated with increased PTSD or depressive symptoms. These data are promising, and psychologists should not be concerned that treating nicotine dependence will be contraindicated in the treatment of clients with other emotional problems.

Brief Clinical Interventions

All counseling psychologists should have the basic clinical skills necessary to implement brief interventions. Long-term abstinence can be greatly increased through the use of brief clinical interventions; the base rate for long-term abstinence is 7% when there is no intervention and 15% to 30% for individuals who receive brief interventions.

Effective brief interventions utilize skills and techniques often associated with motivational intervention strategies. The clinical practice guidelines recommend an approach commonly known as the “Five A’s”: ask, advise, assess readiness, assist, and arrange. Every client should be asked about tobacco use at every visit (ask), and every tobacco user should be encouraged to quit (advise). The client’s willingness to quit should be assessed (assess readiness), and appropriate assistance should be provided to the client (assist). For individuals who are not ready to quit, assistance could be in the form of a brief motivational intervention designed to enhance motivation to change. For those ready to quit, assistance could include providing self-help materials or a referral for a more intensive intervention. Finally, the clinician should arrange to follow up with clients who use tobacco (arrange). Follow-up could be as simple as a phone call to assess smoking status or a scheduled visit to discuss cessation plans. During follow-up, the clinician might congratulate success or help address problems as well as anticipate future challenges. For clients referred for intensive interventions, assessment of treatment is important.

Intensive Clinical Interventions

While all counseling psychologists should be in a position to offer brief clinical interventions for smoking cessation, more intensive intervention will be needed for some clients. These interventions are often provided by clinicians who specialize in treating tobacco dependence and who work in a setting where the primary focus is on smoking cessation. There is substantial evidence that intensive interventions are more effective than brief interventions with respect to cessation success rates; however, many studies have found that only a minority of smokers participate in intensive interventions.

Evidence for intensive interventions suggests several necessary components. First, assessment should ensure that smokers are willing to make an attempt to quit. A willingness to attempt cessation is critical for success. Second, use of multiple types of clinicians is effective and may be desirable. One clinician might provide counseling strategies related to health risk; another clinician might provide pharmacotherapy; and a third clinician might provide additional psychosocial or behavioral interventions.

Third, since there is evidence of a dose-response relationship, it is recommended that intensive treatment use sessions that are at least 10 minutes in duration and that treatment involve four or more sessions. Fourth, the type of intervention (group vs. individual) does not appear to be important. In fact, telephone counseling has been shown to be effective. Fifth, techniques used should be practical (problem solving or skill training), and social support should be provided within sessions and fostered in the client’s environment.

Finally, pharmacotherapy should be encouraged for all smokers, unless there are particular contraindicators for the client. First-line pharmacotherapies include buropion SR, nicotine gum, a nicotine inhaler, nicotine nasal spray, and the nicotine patch. Many of these are over-the-counter medications and do not need a prescription. Special considerations are needed for teens and pregnant individuals.

As noted earlier, intensive treatment should be used by clinicians with specialized training in working with nicotine dependence. However, all psychologists should be aware of the effectiveness of intensive interventions and should make appropriate referrals for their clients who smoke.

Relapse Prevention

The vast majority of cessation attempts result in some type of relapse. It is useful to consider the difference between a brief lapse (an isolated event that is followed by continued abstinence) and a more extensive relapse (a period of several days or more of continued smoking after a period of abstinence). While any form of lapse is very risky and increases the likelihood that the abstinent smoker may return to previous smoking rates, the frequency with which lapses occur suggests that some form of relapse prevention is critical to maximize the chance that a lapse can be followed by continued abstinence, instead of becoming a relapse.

Methods for reducing relapse have included booster sessions, formal relapse prevention training, and enhancing social support. The use of booster sessions alone has not been found to be very useful. Likewise, relapse prevention efforts are at best equivocal. There is some evidence that quickly recruiting individuals who have relapsed into a second course of treatment does not work. Clients who relapse and then try a new pharmacotherapy may fare better in the new attempt.

References:

Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000). Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (December 19, 2005). Decline in teen smoking appears to be nearing its end. University of Michigan News and Information Services: Ann Arbor, MI.
Leffingwell, T. R., & Babitzke, A. C. (2006). Tobacco intervention practices of licensed psychologists. Journal of Clinical Psychology, 62, 313-323.
McFall, M., Saxon, A. J., Thompson, C. E., et al. (2005). Improving the rates of quitting smoking for veterans with posttraumatic stress disorder. American Journal of Psychiatry, 162, 1311-1319.
Piasecki, T. M. (2006). Relapse to smoking. Clinical Psychology Review, 26, 196-215.
U.S. Department of Health and Human Services. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: Author.