7.8 How can relapse be prevented?

Last updated: October 2016 

Suggested citation: Greenhalgh, EM., Stillman, S., & Ford, C. 7.8 How can relapse be prevented? In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2016. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-8-how-can-relapse-be-prevented

Relapse is common, especially in the immediate post-quitting period. Smoking for many people can be regarded as a chronic relapsing disorder, and many smokers may need repeated assistance over the course of their lifetime.1 A longitudinal study in the US spanning 25 years found that among young adults, relapse after quitting was common, with more than a third of smokers relapsing at least once. Relapse was especially likely among those with lower education level.2

There is emerging evidence that while smoking for enjoyment can deter quit attempts, such enjoyment does not predict relapse.3, 4 Cue-driven impulses to smoke, the need for nicotine, adverse moods, and beliefs about the costs and benefits of smoking are important in relapse (see Section 7.7). Relapse prevention efforts should therefore address each of these factors.3

In observing patterns of smoking that occur after quitting, some studies distinguish between a lapse (i.e., at least one puff) and full relapse (i.e., a return to regular smoking).5 Most lapses lead to relapses,5-8 and it is common for there to be a period of intermittent smoking before full relapse occurs.9 Studies have highlighted the dynamic nature of lapse responses during smoking cessation, and suggest that declines in self-efficacy are associated with progression from one lapse to the next.10 Most lapses and relapses occur shortly after quitting,11 highlighting the importance of support during this time. Establishing early abstinence appears to be crucial to establishing longer term abstinence.12 To date, most work has focused on skills-based approaches to identify situations where relapse risk is highest (e.g. socialising with smokers while consuming alcohol) then to develop and rehearse tailored strategies to deal with them in advance.13 For some smokers, their resistance to change is a barrier to quitting. Strategies for overcoming this barrier might include encouraging openness to the possibility of change, breaking down quitting into manageable steps, reframing past failures as learning experiences, subsidising and encouraging the use of quitting aids without overstating their benefit, and encouraging personal responsibility for change.14

One way to conceptualise the challenge of relapse prevention is to see it as three distinct tasks in becoming a non-smoker:

  • To stop smoking (i.e. make a quit attempt).
  • To learn to deal with cravings and other withdrawal symptoms without relapsing.
  • To learn to enjoy and value a smokefree lifestyle, which involves facing old smoking situations without cigarettes, finding new behaviours to substitute for the perceived benefits of smoking, realising that many supposed benefits were illusory, and adopting a new non-smoker self-image.15

Given the chronic nature of nicotine dependence, along with the high likelihood of relapse among those attempting cessation, several studies have explored whether substantially extending the length of interventions could improve quitting outcomes by better aligning with the nature of addiction. Research in the US found that longitudinal care for one year promoted higher rates of long-term abstinence than standard care among participants who did not initially respond to treatment (i.e., were still smoking after 21 days), reflecting a potential care path for smokers who have initial difficulty quitting.16 Extended telephone contact or booster sessions with counsellors, GPs or other support sources have been used extensively and these have been found to have some modest effect on increasing long-term cessation.6 There is some evidence that extended (20-week) cognitive behavioural therapy may help smokers to maintain abstinence in the longer term.17

A 2010 review found that self-help materials appeared to prevent relapse in initially unaided quitters, and found positive results for the use of pharmacotherapies but no definitive evidence regarding behavioural support.18 A more comprehensive review published in 2013 concluded that there is not enough evidence to support the use of any specific behavioural intervention to help smokers avoid relapse. The majority of studies had tested interventions that taught smokers skills in identifying and managing temptations, but these were not found to be effective. In regards to cessation medications, the review found that extended treatment with varenicline may be helpful. The authors highlight the urgent need for studies of extended treatment with nicotine replacement.19

Some common approaches for relapse prevention are outlined below.

7.8.1 Keeping motivation top of mind

Although motivation seems as if it would be an important factor in quitting, and is indeed strongly predictive of making quit attempts, it does not seem to predict sustained cessation.20, 21 While motivation is needed to prompt action to stop smoking, it is not sufficient on its own to maintain cessation.21 This is likely because the determinants of motivation differ before and after a quit attempt. Before an attempt, thinking about the pros and cons of quitting and making estimates of the outcome of the attempt influences decision-making and stimulates trying.22 However, once the person has actually quit, the main determinants of motivation to stay quit are the experiences he or she is having, something people are poor at estimating in advance.23, 24

The key difficulty of motivation in the context of overcoming addiction is that there are counteracting urges and motivations to keep smoking. One way of viewing quitting is as a triumph of rationality over transient desires that are distorted by learned responses and habits associated with addiction. For most smokers, getting to the point of wanting to quit presents a formidable challenge, and there is a strong argument for encouraging and assisting smokers to quit even though they may not have resolved all doubts about quitting.22

Smokers often see their own strength of motivation or will power as being the key to successful quitting, with the implication that they are inadequate if they seek help from others, or if they fail.22, 25 Successful quitters are often perceived as more motivated, while those who relapse are less motivated. However such an analysis does not consider that motivation is a complex, multidimensional concept.

Theories of smoking cessation include a number of elements that can be used to describe motivation.23 In simple terms, motivation is directed action. Motivation is needed for the pursuit of goals, and requires energy, wanting, drive or activity in order to overcome obstacles to achieving these goals. Motivation to quit and stay quit is characterised by ambivalence and conflict, which ebbs and flows as negative thoughts about smoking compete with urges to smoke. Working to resolve this ambivalence may be helped by intrinsic and extrinsic factors: intrapersonal factors such as self-efficacy (belief that one can quit), self-competence, better health, and being a better role model, or environmental factors such as money and social approval. In the self-regulation model, motivation refers to maintaining an optimal state or system balance: if people feel good or neutral then they will maintain their behaviour. Smoking cessation usually results in temporary unpleasant moods, so it is necessary to use coping strategies to avoid returning to smoking. Feedback loops on how behaviour affects mood is an important motivational mechanism: negative affect (unpleasant moods) predicts relapse, but effective coping to decrease negative affect helps maintain cessation.23

Motivational interviewing is a person-centered, goal-oriented style of counselling, which aims to elicit and strengthen people's own motivation and commitment towards behaviour change by helping them resolve their ambivalence and evoking their reasons for change.26 This approach is widely used to help people to quit smoking.27 Common components of motivational interviewing include: exploring ambivalence, decision balance (i.e., weighing pros and cons), assessment of motivation and confidence to quit, eliciting ‘change talk’ (i.e., statements that indicate the person has the desire, motivation, and/or commitment to change their behaviour), and supporting self-efficacy.27

A 2015 Cochrane review concluded that motivational interviewing may assist people to quit smoking, and appears to help more people to quit than brief advice or usual care when provided by general practitioners (GPs) and by trained counsellors. Shorter motivational interviewing sessions (less than 20 minutes per session) were more effective than longer ones. A single session of treatment appeared to be marginally more successful than multiple sessions, but both delivered successful outcomes. The evidence for the value of follow-up telephone support was unclear, and face-to-face counselling was no more helpful than telephone counselling. Both approaches were more successful than brief advice or usual care.27

7.8.2 Anticipating and coping with triggers (stress and mood changes, social pressure and alcohol)

The most widely studied interventions for preventing relapse have used skills building approaches, whereby people learn to identify high-risk situations and are provided with cognitive and behavioural strategies to cope with these situations. A 2013 Cochrane review found that the evidence does not support the effectiveness of this approach, however highlighted that although it may indeed be ineffective, findings could also be due to such skills not being taught effectively. The authors recommend that future studies should try to ascertain whether participants successfully acquired and practised the relevant skills.19

7.8.2.1 Temporary changes in routine

Based on classical conditioning theory, many smoking cessation support services suggest temporary changes in routine and habits that are associated with smoking as a strategy to minimise exposure to smoking cues (see Section 7.3). Smokers commonly smoke when they drink alcohol, and drinking is related to relapse in smoking cessation attempts.28, 29 One study found that alcohol can reduce the ability to resist smoking in a dose-dependent fashion (i.e., the more alcohol that is consumed, the less a person can resist smoking), partly due to its effect on increasing the intensity of smoking urges.30 Therefore, avoiding situations that involve drinking can be helpful in maintaining abstinence from smoking.

7.8.2.2 Dealing with stress and mood disturbance

People attempting to quit tend to relapse not only due to their level of addiction, but also due to immediate precursor factors such as emotional distress.31 Given the association between negative affect following cessation and risk of relapse, strategies that enhance impulse control and help the person to manage negative emotions without the use of cigarettes may help to promote sustained cessation.32 One study found that the inclusion of a mood-management tool in an internet-based cessation intervention increased quitting outcomes.33 Compared to continuing smokers, successful quitters experience improved wellbeing and happiness, which could be communicated to smokers to increase their motivation to quit.34, 35

7.8.3 Managing concerns about weight gain

Experiencing weight gain after quitting can be an important predictor of relapse and can deter subsequent quit attempts.36 Nicotine replacement products and bupropion appear to be modestly effective in postponing some of the weight gain that often accompanies cessation.37-40 Nicotine gum may have the potential to minimise weight gain in the long term if higher doses are used properly, more often.41 Other pharmacological interventions have shown initial weight gain reduction, but this was not maintained in the longer term.40 Advice to attenuate weight gain includes engaging in physical activity, having a healthy diet and limiting alcohol consumption;38, 39 42-46 however, such advice does not appear to reduce weight gain and may in fact reduce abstinence from smoking.40 Studies on simultaneous quitting and dieting to prevent weight gain have produced mixed results: some found that it undermined the attempt to quit smoking, while others reported similar or higher rates of success for smoking cessation in specific populations.39 Some researchers suggest that a self-control strength model, where self-regulation relies on limited strength that is depleted with use, may explain why dieting undermines cessation attempts.47 One study suggests that for weight-concerned female smokers, success in changing eating behaviour may increase self-efficacy for quitting smoking.48 Another study found that mindfulness (see Section 7.8.5, below) weakens the link between smoking-related weight concerns and smoking behaviour among young women.49 A systematic review and meta-analysis of behavioural interventions that promote smoking cessation and prevent weight gain concluded that while there is no evidence that such interventions produce any harm and significant evidence of short-term (less than three months) benefit for both abstinence and weight control, research to date does not show long-term effectiveness.50

A 2012 Cochrane review concluded that some pharmacotherapies (bupropion, fluoxetine, NRT and varenicline) show short-term success in reducing post-cessation weight gain, but long-term evidence is limited. Personalised weight management support may be effective and not reduce abstinence, but more studies are needed. One study showed a very low calorie diet increased abstinence but did not prevent weight gain in the longer term. Ineffective interventions included weight management education, and cognitive-behavioural therapy to accept weight gain. Exercise interventions significantly reduced weight in the long term but not the short term, but further studies are needed to clarify this relationship. Overall, there was not enough data to make strong clinical recommendations.51

7.8.4 Managing cravings

The management of cravings, which are typically most intense within the first few days after quitting, is complicated by the high variability in symptoms across individuals and time, as well as by the lack of a definitive number or severity of symptoms that lead to relapse.52 Investigating how smokers react to the discomfort of nicotine withdrawal and quitting smoking may have important implications for developing specialised treatments.53 A number of studies support the use of exercise to help decrease cravings to smoke,54, 55 and acute exercise may provide additional craving relief on top of that provided by NRT in recently quit smokers.56

7.8.4.1 Distractions

Distractions, together with breathing exercises and eating/drinking, are among the most commonly used techniques to cope with cravings to smoke.57 For example, researchers in the UK found that playing Tetris significantly decreases cigarette cravings in real-world settings. They explained that craving involves imagining the experience of consuming a particular substance, and playing Tetris (a visually interesting game) occupies the mental processes that support that imagery. It is difficult to imagine something vividly (i.e., crave it) and play Tetris at the same time.58 Researchers have also started to explore the use of mobile phone apps as a source of distraction during cigarette cravings.59

7.8.4.2 Medication to reduce cravings and other withdrawal symptoms

Smoking cessation medications primarily aim to reduce withdrawal symptoms and block the reinforcing effects of nicotine.60 Pharmacotherapies may be particularly helpful for more dependent smokers, and are effective for increasing smoking abstinence rates, at least in the short term.61, 62 However, a systematic review of relapse prevention strategies found that there is substantial relapse to smoking after drug treatment courses are finished.63 A 2013 Cochrane review found that extended treatment with varenicline may prevent relapse, but extended treatment with bupropion is unlikely to have a clinically important effect.19 Nonetheless, economic analyses of the use of pharmacotherapies for cessation suggest they are highly cost effective.63, 64 (See Section 7.16 and Chapter 17 for more detailed information on pharmacotherapies.)

7.8.5 Social support

Some findings suggest that social support affects relapse. Limited evidence indicates that a high percentage of partners are willing to help their partner who smokes and are interested in learning ways to help.65 However a 2012 Cochrane review of interventions designed to enhance partner support for smokers in cessation programs failed to detect an increase in quit rates, but highlighted that more research is needed to adequately explore the effects of partner support interventions for smoking cessation.66 An analysis of combined data from three randomised clinical trials found that positive social support predicted success in the early phase of quitting, while the absence of unhelpful and negative behaviours (such as expressing doubt and nagging) from important others best predicted maintained abstinence.67

7.8.6 Mindfulness

The concept of mindfulness has roots in Buddhist and other contemplative traditions. It is often described as the state of being attentive to and aware of what is taking place in the present.68 Mindfulness is an inherent human capability that can be learned and trained, and its practice has been linked with a range of improved health outcomes.69 It allows people to reduce their negative and increase their positive affect, and improve their overall wellbeing.70

A growing body of research supports the effectiveness of mindfulness-based interventions for smoking cessation. Smokers, especially female smokers, have lower levels of mindfulness and wellbeing than non-smokers, leading researchers to suggest that mindfulness-based interventions may help smokers to deal with treatment and abstinence by increasing their level of wellbeing.70 Mindfulness strategies for managing nicotine cravings involve present-moment, nonjudgemental awareness of cravings without acting on them.71

A review of addiction research found that exercises aimed at increasing self-control, such as mindfulness meditation, can decrease the unconscious influences that cause cigarette cravings. For example, one study showed that mindfulness meditation training led to a subconscious reduction in smoking. Although participants who had completed the training reported smoking the same number of cigarettes, an objective measure of carbon dioxide percentage in their lungs suggested a 60 per cent reduction in quantity of smoke inhaled over two weeks after the study.72 Researchers in the US found that mindfulness training led to significantly higher abstinence rates among a group of socioeconomically disadvantaged smokers.73 Mindfulness practice appears to reduce negative affect, craving, and cigarette use among smokers who are trying to quit.74 A 2015 systematic review concluded that mindfulness-based interventions show promise for the treatment of smoking, especially for cessation, relapse prevention, number of cigarettes smoked, moderating the relationship between craving and smoking, and the development of coping strategies to deal with triggers to smoke. The positive effects of mindfulness on mental health might contribute to the maintenance of tobacco abstinence.75


Relevant news and research

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