Nicotine Dependency Treatment: - New Opportunities for Psychologists
by Marlene M. Maheu, Ph.D.
The World Health Organization estimates that one in every ten people alive today will die a tobacco-related death. Approximately 1,200 people per day die in the United States alone. What can we do to provide service?
Opportunities abound in numerous arenas. Physicians need good referral sources, and often are only aware of public health resources or hospital-based programs. Specialized practitioners are needed in-patient (bedside treatment, chemical dependency treatment) as well as outpatient. Worksite intervention is another avenue for programming, and can lead to practice-building opportunities. Researchers are also needed ample funding is available for warranted investigations with specialized populations.
Nicotine as a Drug
What are some of the similarities and differences between nicotine dependency and the other chemical dependencies? Much of this answer revolves around the addictive substance in tobacco, nicotine. It is the only addictive substance listed in the DSM IV that does not have an abuse category - it is only classified under "dependence," the more severe of the two designations. In 1988, Surgeon General Koop stated, "The pharmacological and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine."
Which DSM-V criteria for dependency are met by nicotine? Nicotine dependent individuals experience increased tolerance; preoccupation with the substance; continued use despite impairment; withdrawal symptoms upon cessation; and cause harmful effects to others (passive smoke). Other interesting aspects about this drug include: nicotine is the only substance that acts as a central nervous system stimulant OR depressant; nicotine significantly increases metabolic rate, making it difficult to regulate weight gain during the first year of abstinence; and 80% of alcoholics are nicotine dependent. Nicotine is seen as being as addictive as alcohol or heroin. It is usually the first drug used and the last drug given up by individuals. Ninety percent of alcohol drinkers don't become dependent on alcohol; yet only ten percent of nicotine users don't become dependent on nicotine. Twenty-five percent of the American population is nicotine dependent, and twenty percent of the California population is dependent.
Client Population and Interventions
Most individuals still using tobacco are more heavily dependent than smokers of a decade ago. They may have tried to quit several times and failed, and feel quite hopeless about another attempt. As clinicians, we are in the best position to deal with impaired self esteem and offer psycho-educational interventions for individuals who fail with physician-based and/or public health programs (such as Lung Association and Cancer Society programs.) We also are in the best position to diagnose underlying DSM III-R Axis I diagnoses related to anxiety and/or depression. These disorders may appear dramatically upon nicotine cessation, but mistaken for "unbearable" withdrawal symptoms by either the client or family members. A history of psychiatric medication and repeat failure at nicotine cessation warrants the initiation of either sedative or activating anti-depressants two weeks prior to cessation. You may want to suggest sedative anti-depressants rather than anxiolytics for anxiety management.
The most helpful model for understanding the process of change for tobacco users is one developed by Prochaska and DiClemente (1992.) They outline the "Transtheoretical Model," and identify six "Stages of Readiness to Change." These stages are: pre-contemplation (20% of smokers), contemplation (60% of smokers), preparation, action, maintenance, and relapse. Pre-contemplators are considered "happy smokers," who "don't have a problem" with tobacco use. They may have failed numerous times before. While the hardest for us to reach, they can be influenced by respectful, non-threatening probing.
Contemplators are "on the fence." They are caught in the "decisional balance." They have a list of reasons for continuing tobacco use on one side of the scale, and a list of reasons for stopping on the other. Our job is to help them identify both sides of the scale, and resolve whatever can be changed on the side weighted toward continuing tobacco use. The most difficult part is to accomplish this task respectfully, without pressure or aversion. They may also be "on the fence" about whether now is a good time to stop their tobacco use. Being realistic is important. A recent divorcee who just lost her job is not a good candidate for smoking cessation in the next few months. Helping her outline reasonable goals for emotional stability, and how to achieve those goals must be the prime focus with such an individual.
The preparation stage is begins one month prior to a cessation attempt. This is when individuals approach us and ask for help in stopping tobacco use. The action stage is when someone is actually making the cessation attempt. Maintenance is recognized six months after successful cessation. Relapse can occur anytime after cessation, but generally occurs within three months of the cessation attempt. Two-thirds of those who relapse do so within these three months. (One third of all relapse occurs when someone is drinking alcohol.)
Diagnosis for motivational stage is relatively simple. Asking your client to self-identify as "not ready," "unsure," or "willing" can tell you if they are in the pre-contemplative, contemplative, or preparation stage.
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