Clinical interventions promoting individual change

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I Perceived stress scale (Cohen et al. 1985), which measures how much perceived stress
the individual has experienced in the last month.
I Fagerstrom Tolerance Questionnaire which measures physical tolerance to nicotine.
I Smoking decisional balance scale (Velicer et al. 1985), which measures the perceived
pros and cons of smoking.
I Smoking processes of change scale (DiClemente and Prochaska 1985), which measures
the individual’s stage of change. According to this scale, subjects were defined as
precontemplators (n = 166), contemplators (n = 794) and those in the preparation
stage (n = 506).
I Demographic data, including age, gender, education and smoking history.
Results
The results were first analysed to examine baseline difference between the three subject
groups. The results showed that those in the preparation stage smoked less, were less
addicted, had higher self-efficacy, rated the pros of smoking as less and the costs of
smoking as more, had made more prior quitting attempts than the other two groups. The
results were then analysed to examine the relationship between stage of change and
smoking cessation. At both one and six months, the subjects in the preparation stage had
made more quit attempts and were more likely to not be smoking.
Conclusion
The results provide support for the stages of change model of smoking cessation and
suggest that it is a useful tool for predicting successful outcome of any smoking cessation
intervention.
INTERVENTIONS TO PROMOTE CESSATION
Interventions to promote cessation can be described as either (1) clinical interventions,
which are aimed at the individual; (2) self-help movements; or (3) public health interventions, which are aimed at populations.
Clinical interventions: promoting individual change
Clinical interventions often take the form of group or individual treatment programmes
based in hospitals or universities requiring regular attendance over a 6- or 12-week
period. These interventions use a combination of approaches that reflect the different
disease and social learning theory models of addiction and are provided for those
individuals who seek help.
Disease perspectives on cessation Within the most recent disease models of
addiction, nicotine and alcohol are seen as addictive and the individual who is addicted
is seen as having acquired tolerance and dependency to the substance. Accordingly,
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cessation programmes offer ways for the individual to reduce this dependency. For
example, nicotine fading procedures encourage smokers to gradually switch to brands of
low nicotine cigarettes and gradually to smoke fewer cigarettes. It is believed that when
the smoker is ready to completely quit, their addiction to nicotine will be small enough to
minimize any withdrawal symptoms. Although there is no evidence to support the
effectiveness of nicotine fading on its own, it has been shown to be useful alongside other
methods such as relapse prevention (for example, Brown et al. 1984).
Nicotine replacement procedures also emphasize an individual’s addiction and dependency on nicotine. For example, nicotine chewing gum is available over the counter and
is used as a way of reducing the withdrawal symptoms experienced following sudden
cessation. The chewing gum has been shown to be a useful addition to other behavioural
methods, particularly in preventing short-term relapse (Killen et al. 1990). However, it
tastes unpleasant and takes time to be absorbed into the bloodstream. More recently,
nicotine patches have become available, which only need to be applied once a day in
order to provide a steady supply of nicotine into the bloodstream. They do not need to be
tasted, although it could be argued that chewing gum satisfies the oral component of
smoking. However, whether nicotine replacement procedures are actually compensating
for a physiological addiction or whether they are offering a placebo effect via expecting
not to need cigarettes is unclear. Treating excessive drinking from a disease perspective
involves aiming for total abstinence as there is no suitable substitute for alcohol.
Social learning perspectives on cessation Social learning theory emphasizes
learning an addictive behaviour through processes such as operant conditioning
(rewards and punishments), classical conditioning (associations with internal/external
cues), observational learning and cognitions. Therefore, cessation procedures emphasize
these processes in attempts to help smokers and excessive drinkers stop their behaviour.
These cessation procedures include: aversion therapies, contingency contracting, cue
exposure, self-management techniques and multi-perspective cessation clinics:
1 Aversion therapies aim to punish smoking and drinking rather than rewarding it.
Early methodologies used crude techniques such as electric shocks whereby each time
the individual smoked a puff of a cigarette or drank some alcohol they would receive
a mild electric shock. However, this approach was found to be ineffective for both
smoking and drinking (e.g. Wilson 1978), the main reason being that it is difficult to
transfer behaviours that have been learnt in the laboratory to the real world. In an
attempt to transfer this approach to the real world alcoholics are sometimes given a
drug called Antabuse, which induces vomiting whenever alcohol is consumed. This
therefore encourages the alcoholic to associate drinking with being sick. This has
been shown to be more effective than electric shocks (Lang and Marlatt 1982), but
requires the individual to take the drug and also ignores the multitude of reasons
behind their drink problem. Imaginal aversion techniques have been used for smokers
and encourage the smoker to imagine the negative consequence of smoking, such as
being sick (rather than actually experiencing them). However, imaginal techniques
seem to add nothing to other behavioural treatments (Lichtenstein and Brown 1983).
Rapid smoking is a more successful form of aversion therapy (Danaher 1977) and
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aims to make the actual process of smoking unpleasant. Smokers are required to sit in
a closed room and take a puff every 6 seconds until it becomes so unpleasant they
cannot smoke any more. Although there is some evidence to support rapid smoking
as a smoking cessation technique, it has obvious side effects, including increased
blood carbon monoxide levels and heart rates. Other aversion therapies include
focused smoking, which involves smokers concentrating on all the negative experiences of smoking and smoke-holding, which involves smokers holding smoke in their
mouths for a period of time and again thinking about the unpleasant sensations.
Smoke-holding has been shown to be more successful at promoting cessation than
focused smoking and it does not have the side effects of rapid smoking (Walker and
Franzini 1985).
2 Contingency contracting procedures also aim to punish smoking and drinking and
to reward abstinence. Smokers and drinkers are asked to make a contract with either
a therapist, a friend or partner and to establish a set of rewards/punishments, which
are contingent on their smoking/drinking cessation. For example, money may be
deposited with the therapist and only returned when they have stopped smoking/
drinking for a given period of time. They are therefore rewarding abstinence.
Schwartz (1987) analysed a series of contingency contracting studies for smoking
cessation from 1967 to 1985 and concluded that this procedure seems to be successful in promoting initial cessation, but once the contract was finished, or the money
returned, relapse was high. In a study of alcoholics, 20 severe alcoholics who had
been arrested for drunkenness were offered employment, health care, counselling,
food and clothing if they remained sober (Miller 1975). The results showed that those
with the contracts were arrested less, employed more, and were more often sober
according to unannounced blood alcohol checks than those who were given these
‘rewards’ non-contingently. However, whether such changes in behaviour would persist over time is unclear. In addition, this perspective is reminiscent of a more punitive
moral model of addictions.
3 Cue exposure procedures focus on the environmental factors that have become
associated with smoking and drinking. For example, if an individual always smokes
when they drink alcohol, alcohol will become a strong external cue to smoke and vice
versa. Cue exposure techniques gradually expose the individual to different cues and
encourage them to develop coping strategies to deal with them. This procedure aims
to extinguish the response to the cues over time and is opposite to cue avoidance
procedures, which encourage individuals not to go to the places where they may feel
the urge to smoke or drink. Cue exposure highlights some of the problem with inpatient detoxification approaches to alcoholism whereby the alcoholic is hospitalized
for a length of time until they have reduced the alcohol from their system. Such an
approach aims to reduce the alcoholic’s physiological need for alcohol by keeping
them away from alcohol during their withdrawal symptoms. However, being in
hospital does not teach the alcoholic how to deal with the cues to drink. It means that
they avoid these cues, rather than being exposed to them.
4 Self-management procedures use a variety of behavioural techniques to promote smoking and drinking cessation in individuals and may be carried out under
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professional guidance. Such procedures involve self-monitoring (keeping a record of
own smoking/drinking behaviour), becoming aware of the causes of smoking/
drinking (What makes me smoke? Where do I smoke? Where do I drink?), and
becoming aware of the consequences of smoking/drinking (Does it make me feel
better? What do I expect from smoking/drinking?). However, used on their own, selfmanagement techniques do not appear to be more successful than other interventions
(Hall et al. 1990).
5 Multi-perspective cessation clinics represent an integration of all the above
clinical approaches to smoking and drinking cessation and use a combination of
aversion therapies, contingency contracting, cue exposure and self-management. In
addition, for smoking cessation this multi-perspective approach often incorporates
disease model based interventions such as nicotine replacement. Lando (1977)
developed an integrated model of smoking cessation, which has served as a model for
subsequent clinics. His approach included the following procedures:
I six sessions of rapid smoking for 25 minutes for one week;
I doubled daily smoking rate outside the clinic for one week;
I onset of smoking cessation;
I identifying problems encountered when attempting to stop smoking;
I developing ways to deal with these problems;
I self-reward contracts for cessation success (e.g. buying something new);
I self-punishment contracts for smoking (e.g. give money to a friend/therapist).
Lando’s model has been evaluated and research suggested a 76 per cent abstinence
rate at six months (Lando 1977) and 46 per cent at twelve months (Lando and
McGovern 1982), which was higher than the control group’s abstinence rates. Killen
et al. (1984) developed Lando’s approach but used smoke holding rather than rapid
smoking, and added nicotine chewing gum into the programme. Their results showed
similarly high abstinence rates to the study by Lando.
Multi-perspective approaches have also been developed for the treatment of
alcohol use. These include an integration of the above approaches and also an
emphasis on drinking as a coping strategy. Drinking is therefore not simply seen as
an unwanted behaviour that should stop but as a behaviour which serves a function
in the alcoholic’s life. Such approaches include:
I Assessing the drinking behaviour both in terms of the degree of the problem (e.g.
frequency and amount drank) and the factors that determine the drinking
(e.g. What function does the drinking serve? When does the urge to drink increase/
decrease? What is the motivation to change? Do the individual’s family/friends
support their desire to change?).
I Self-monitoring (e.g. When do I drink?).
I Developing new coping strategies (e.g. relaxation, stress management).
I Cue exposure (e.g. learning to cope with high-risk situations).
Multi-perspective approaches are often regarded as skills training approaches as they
encourage individuals to develop the relevant skills needed to change their behaviour.
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