ATTUD Journal Club Postings

Recycling Relapsers

This month’s blog focuses on options once a smoker has relapsed (is smoking regularly – usually defined as smoking for 7 consecutive days).

The advice for lapses in the last blog also applies for relapses; i.e., discuss the possibility of lapse/relapse at treatment initiation, explore what caused the relapse and problem solve, continue medication, and smoke as little as possible. There is a belief that it’s best for relapsers to wait and recover from the disappointment of failure before they try to stop again. There is no evidence for this notion. In fact, studies show that, even right after a relapse, most relapsers have high motivation to quit again in the near future. Thus, I think it best to encourage smokers to quit again as soon as they are ready. Many forget that making a quit attempt is a strong marker that one is motivated to change. One possibility is to proactively call relapsed smokers every 2-3 months and ask if they have reconsidered making a new attempt. Many smokers state this follow-up is important as it indicates the clinician has not given up on them.

So if a smoker agrees to quit again, how should treatment change? It is difficult for smokers to know if their relapse was due to the failure of the treatment or their own lack of commitment. One important question is how compliant were they in the period prior to the relapse. If compliant, then clearly a new treatment is needed. If not compliant, then exploration for the reasons for the noncompliance is needed.

Usually, smokers want a new treatment. The first question then is whether what was lacking was adequate psychosocial or adequate medication treatment. Asking about environmental precipitants to the relapse and about craving and withdrawal   right before the relapse can be helpful. Some smokers who use only medication have a strong belief that using counseling is sign of weakness, is unpleasant, etc. and some who use only counseling think the same thing about using medication. Thus, a common issue is convincing a smoker that, for some smokers, using medications alone or using counseling alone is unlikely to work.

In choosing treatments, one important question is whether the smoker thought the prior treatment helped. If so, then the discussion should focus on adding a new treatment. For both psychosocial and medication treatments, one possibility is simply increasing the intensity/dose. Another possibility is to add or switch to a new class of treatments; e.g. from internet to group counseling or from nicotine to non-nicotine medications.

Why should fully relapsed smokers continue their medication and smoke less? Many studies have found that medication-induced reduction in cigs/day increases the probability of quitting. Plus, several studies have found no medical harm from long-term concurrent use of nicotine replacement medications and smoking. Although similar studies have not been done for non-nicotine medications, there is no reason to believe their long term use causes problems. If short-acting nicotine medications are used, there is a risk of dependence on these meds, but this risk is small (< 5% of users).  Given this, I suggest encouraging smokers to continue their medication as long as they believe they are receiving its benefits. I have had patients who smoked 20 cigs/day, quit with nicotine patch, relapse and use patch plus a few cigarettes (e.g. 5/day) for months, and then try to quit again. The one down side to this is that it is clearly off-label use of these medications.

How should psychosocial treatment change? First, I think it’s best to change the goal from “re-establishing abstinence” to “making a new quit attempt.” The reason for this, is that I think relapsers need to cognitively “purge” the old unsuccessful attempt, learn from it, and believe they are starting a new attempt, not contaminated by the prior failure. Second, the learnings from the prior failure need to be converted to concrete new plans. Smokers need to believe they have a new weapon when trying to quit again.

Again, I would love to hear your thoughts on this and feel free to share this with others.