Approaches to the Tobacco Addiction Problem

It is established that a majority of smokers (as many as 70%) desire to quit, but only 30% actually try each year, and only 3%- 5% actually succeed in quitting.

Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence. Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments:

• Patients willing to try quitting tobacco use should be provided with treatments identified as effective.

• Patients unwilling to try quitting tobacco use should be provided with a brief intervention designed to increase their motivation to quit.

Brief interventions offered by physicians and other primary health care personnel are valuable in the management of individuals with tobacco-related problems. They are low in cost and have proven to be effective in tobacco cessation. The physician has the influence, as a credible expert in a position of authority, to suggest and advise patients to quit tobacco use.

Simple advice alone administered by a physician, which can take as little as 30 seconds, can produce quit rates of 5-10% per year. Such interventions fill the gap between primary prevention efforts and more intensive treatment for persons with long-standing and more intractable addiction to tobacco.

Not every person is ready to change their nicotine habit, and studies have identified a consistent behavior change pattern, which may be helpful in understanding and facilitating change. The trans-theoretical model emphasizes stages of change:

• Pre-contemplation

• Contemplation

• Preparation

• Action

• Maintenance

• Termination

The key features of this model are that an individual’s readiness to change can be assessed; and that specific interventions are tailored to the person’s stage of change, in order to increase the likelihood of success.

Intensive Counseling by a specialist increases quit rates additionally by 4-7% compared to normal. Relapse prevention strategies given individually suggest increased cessation rates by about 1.5 - 2%. Numerous effective pharmacotherapy for tobacco cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit tobacco use.

Pharmacological interventions when used with behavioral strategies can produce quit rates of about 25 –30 %. Pharmacotherapy that reliably increase long-term smoking abstinence rates include:

a). Agents that appear to decrease craving,

b). Agents, which are used to substitute the nicotine, obtained from tobacco,

• Nicotine gum

• Nicotine patch

• Nicotine inhaler or Nicotine nasal spray

• Nicotine replacement Therapy (NRT) is useful and associated with quit rates of about 23% as against 13% with placebo.

Helping People Change

Most clinicians involved in smoking cessation have felt discouraged when, despite their best efforts and genuine desire to be helpful, the person they are trying to help doesn’t seem to be changing. They may wonder whether their clients are unmotivated, or think their patients are denying or rationalizing away the risks of smoking. The clinician may become frustrated when detailed information and a range of coping strategies appear insufficient to increase motivation to quit.

Why do people not change?

There are usually four forces, which influence change; Forces keeping a person in his/her current behavior:

– What I like about my current behavior,

– What I fear about the new behavior Forces encouraging change to a new behavior,

– What I dislike about my current behavior,

– What I imagine the advantages of the new behavior would be.

When people feel that what they like about their tobacco use and what they fear (anticipate) about what will happen if they stop is more compelling than what they dislike about using tobacco and what they imagine would be good about becoming a nonuser, then the chances that they will think about quitting is rather remote.

Ignorance about the consequences of their use or lack of knowledge about effective quitting strategies, denial of problems faced because of tobacco use, personal choices related to lifestyle or perceived self-image, anger and entitlement, defiance or even a fear of failure (because of earlier failed attempts at quitting) are the major factors that discourage change.

These perceptions and feelings are not rigid and stable. At various stages in their lives people tend to attach more or less emotional significance to each of these four factors. In effect this is like a continual balancing game with people see-sawing from one decisional end to another. The clinician’s goal is to be able to help the person tip the balance so as to favor a decision to change.

Quitting does not happen in one step – people progress through five stages on the way to successful change. In each of the stages a person has to grapple with a different set of issues and tasks that relate to their tobacco using behavior.