Nicotine Dependency Treatment: - New Opportunities for Psychologists

by Marlene M. Maheu, Ph.D.

Nicotine Dependency Treatment: New Opportunities

Here are stage-appropriate interventions suggested by Steven Rollnick:

1. PRE-CONTEMPLATION - Ask about tobacco use during the intake interview. "Do you smoke (chew, dip)? What do you like about using tobacco? What do you like less about tobacco? Have you ever tried to stop? What happened? Are you thinking of stopping sometime in the future?" Include questions regarding tobacco on your regular office intake form.

2. CONTEMPLATION - When the individual mentions tobacco use as a problem during treatment for another problem, ask: "What do you like about tobacco? What do you like less? Why is now not a good time to stop? What is now a good time to stop?"

3. PREPARATION - Give information about cessation options. Have a list of appropriate referrals, or if you offer treatment, help the individual outline a reasonable plan. Discourage simultaneous attempts to diet and begin strenuous exercise programs. Moderation with other goals is the key when stopping any form of tobacco use.

4. ACTION - Make direct suggestions. Assist by encouraging individuals to take inventory of daily tobacco use; identify difficult times; develop methods to handle them; set a reasonable stop date at least two weeks into the future; rid their environment of all tobacco and products; develop and begin using a support system; increase exercise moderately; regulate food intake; and recommend physician contact if they want nicotine replacement therapy (often very helpful if used properly). Provide self-help materials. The Cancer Society offers a well-prepared free packet. Make contact with the smoker's physician or psychiatrist. In a simple letter, outline the patient's need for support, highlighting this dependency as a serious issue. One or two follow-up visits with the physician in addition to regular visits with us can be very helpful. Success rates improve with the number of modalities used. Make all referrals from your office telephone with the patient present to increase chances of follow-through.

5. MAINTENANCE - Repeatedly "check-in." This stage is easily neglected, as we sink back into our own complacency. We need to repeatedly bring up the issues with questions such as "How was it for you this week? Did you have any cravings? Did you have any successes? What worked?" Encourage individuals to avoid other smokers, parties, or other trigger situations for a few months. Use role-play techniques. Role playing difficult situations can help. Alternative coping strategies need to be developed and practiced in session, if possible. Moderate exercise should be reinforced.

6. RELAPSE - Address relapse directly. This is a very delicate time. Focus on: "What did you learn about yourself "(seek negative self-attribution and disarm it). Ask, "What did you learn about that situation?" to put blame on a bad situation. Use questions such as, "What was happening just before you chose to buy cigarettes? What were you thinking as you lit up? What are you telling yourself now about your ability to quit again?" You probably will only get one opportunity to discuss failure at length with a tobacco user who has recently slipped. Proper focus is important. Correcting yourself the next week is often too late. By then, they probably would have made the decision to smoke at least a hundred times, and their desire to stop will be buried beneath layers of hopelessness and embarrassment.

Focusing on the successes more than the failures helps build confidence. If someone overcame a thousand cravings and gave into one, focus on the one thousand correct responses. Ask about those situations, cognitions, and behaviors. Referral to an adjunctive specialist, a private or hospital-based program can be life-saving if the individual is failing repeatedly. Or, seek specialized training. Such training programs offering basic to advanced nicotine treatment skills for clinicians are beginning to emerge.

Most importantly, remember to avoid your own passivity. Keeping silent about the issue is condoning and colluding. Avoid intimidation or veiled threats of future disease and/or demise. Aversive techniques don't increase motivation for tobacco users; physicians can more successfully link symptoms with tobacco use. Avoid humiliating or shaming. A typical response from a smoker or chewer is increased resistance or overt anger. Avoid pushing for a stop date. Educate slowly. Remember to address chewing tobacco and snuff. Some people celebrate smoking cessation but continue to use smokeless tobacco secretly.

Successful Program Components

For programming successful interventions, significant research has shown several factors to be important.

Group and individual contact is better than either alone. The greater the number of modalities (written materials, professional contact, videos, television etc.,) the higher the success rate. Physician and non-physician counseling are helpful together. The greater the number of contacts, the better. The greater the number of months of intervention, the better; Relapse prevention techniques focused on cognitive-behavioral skill development is optimal. Biochemical verification of smoking status is very helpful in corporate and hospital as well as private practice settings.

Our expertise and services are desperately needed to address "the single most important cause of preventable disease," as repeatedly identified by all our recent Surgeon Generals. Join the ranks of those who are fighting the tobacco industry's greedy destruction. This work is heartening, rewarding and can make you feel like a life-saving hero or heroine. And for most clients, this can be accomplished in under ten sessions.


Other Resources

Dr. Maheu is an author, speaker, and researcher. She is the lead author of E-Health, Telehealth & Telemedicine: A Guide to Program Startup and Success co-written with Pamela Whitten and Ace Allen, published by Jossey-Bass: San Francisco.

Infidelity on the Internet is Dr. Maheu's second book and she's currently working her third, tentatively titled "The Mental Health Professional Online: New Questions and Answers."

For more information about her speaking schedule, see this page: