Preventing relapse in the treatment of nicotine addiction: current issues and future directions.

Journal of Psychoactive Drugs

ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20

Preventing Relapse in the Treatment of Nicotine Addiction: Current Issues and Future Directions Timothy P. Carmody To cite this article: Timothy P. Carmody (1990) Preventing Relapse in the Treatment of Nicotine Addiction: Current Issues and Future Directions, Journal of Psychoactive Drugs, 22:2, 211-238, DOI: 10.1080/02791072.1990.10472545 To link to this article: http://dx.doi.org/10.1080/02791072.1990.10472545

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of Nicotine Addiction: Current Issues and Future Directions Timothy P. Carmody, Ph.D. * Abstract - Although smoking-cessation rates have continued to increase, the vast maj ority of smokers who quit eventually relapse. Between 1974 and 1985, over 1.3 million smokers quit during each of those years. However, 75% to 80% of those individuals resumed smoking within six months. This article describes the dynamic phenomenon of smoking relapse within the context of cyclical episodes of smoking and quitting during an individual's lifetime. Theories of the determinants of smoking relapse are reviewed and methods designed to prevent relapse are described. Smoking relapse is discussed in terms of three aspects of tobacco addiction: (1) biological-addiction mechanisms, (2) conditioning processes, and (3) cognitive-social learning factors. The major determinants of smoking relapse are reviewed, including nicotine withdrawal, stress, weight gain, social influences, conditioning factors, causal attributions, and environmental variables. A transtheoretical-developmental model is explored in the longitudinal investigation of the natural history of slips (lapses) and relapse episodes. Relapse prevention interventions are described that emphasize self-awareness, self-regulation, self-efficacy, affect regulation, social support, and lifestyle balance. Recent developments in pharmacological adjuncts to treatment are also examined. It is concluded that innovative relapse prevention methods need to be designed for hard-core smokers with histories of cessation failures. substance abuse and/or psychiatric impairment. These and other recommendations for future research on smoking relapse and relapse prevention are discussed.

Keywords - addiction, cessation, nicotine, relapse, smoking, tobacco

Cigarette smoking is recognized as the leading cause of preventable death in the United States (Sees & Clark 1988; Slade 1988). The death rate among smokers is 30% to 80% higher than the death rate among nonsmokers (Holbrook 1983). It is estimated that 350,000 to 450,000 deaths per year in the United States are due to medical consequences directly linked to cigarette smoking (Slade 1988; Fielding 1985). In 1985, the total direct health care costs of smoking-related illnesses exceeded $16 billion. The indirect costs of smoking-related illnesses for that same year (i.e., lost productivity and earn-

ings from excess morbidity, disability, and premature deaths) totaled more than $37 billion (Fielding 1985). These serious and epidemic health consequences of cigarette smoking make it imperative to better understand this addictive behavior and thereby take steps to minimize the phenomenon of smoking relapse. From 1974 to the present, the prevalence of cigarette smoking in the United States has declined at a steady rate. According to recent data from the National Health Interview Survey (pierce et al. 1989b), approximately 1.3 million persons per year have quit smoking since 1974. This decline in smoking prevalence has occurred across all race, gender, and educational categories, although at a

·Psychology Service (1168), Department of Veterans Affairs Medical Center, 4150 Clement Street, San Francisco,California94121.

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slower rate for women and lower educational groups (Fiore et al. 1989). The rate of decline in smoking prevalence has been twice as fast among higher-educated groups (Pierce et al. 1989a). What these data do not show is the relapse rate among those smokers who quit either on their own or with outside help.

recommended at the National Working Co nference on Smokin g Relapse will be used. At that conference, OssipKlein and colleagues (1986) propos ed that a relapse episode be defined as seven consecutive days of smoking at least one puff per day following a period of total abstinence. They further proposed that a lapse (slip), in contras t to a relapse episode , be defin ed as an iso la ted smoking episode (i.e ., not more than six consec uti ve days) followed by a t least 24 ho urs of abstinence. Furthermore, a relapse crisis was defined as any situation in which the temptation to smoke occ urs. Full-blown relapse (i.e., resumption of regular smoking for more than a week) can be viewed in terms of outcome (i. c., recurrence of smoking aft er a period of abstinence) or process (i.e., the act of recidivism or backsliding). A lapse or relapse episode, on the other hand, describes a single event in which correc tive action ca n be taken becau se control has not bee n completely lost.


DESCRIPTIVE ANALYSIS OF SMOKING RELAPSE Most smoking-cessation programs are generally quite effective in helping people to stop smoking, but only temporarily. Although smoking-cessation rates at posttreatment typically range from 70% to 90%, up to 80% of those smokers who initially succeed in stopping smoking eventually relapse over the 12-month period following initial cessation (Lichtenstein, Glasgow & Abrams 1986; Marlatt & Gordon 1985, 1980). This figure is consistent with relapse rates for most addictions, which range from 50% to 90% (Brownell et aI. 1986b; Marlatt & Gordon 1985). Studies that have followed smokers beyond one year have shown that approximately 25% to 30% of originally treated subjects are abstinent from two to six years after being terminated from initial smoking ces sation treatment (e.g., Colletti, Supnick & Rizzo 1982). However, there is considerable interindividual variability hidden within such average relapse rates. Furthermore, these data are derived from clinical treatment programs and it is well known that most smokers who attempt to quit do so on their own. Whether or not sex differences exist in smoking relapse has been the subject of considerable debate. In the recent Adult Use of Tobacco Survey conducted by the Office on Smoking and Health of the Centers for Disease Control (Pierce et al. 1989c), the results showed that 20% more men than wom en were long-term ex -smokers. Thirty percent of men and 25% of women who had ever smoked had quit for longer than five years. Some experts have concluded from such data that women are more prone to smoking relapse than men. However, these sex differences may simply reflect the fact that the prevalence of smoking behavior peaked earlier historically for men than for women (U.S. Department of Health and Human Services 1980).

Natural History of Smoking Relap se There is little data available from prospective longitudinal studies describin g the natural history of smoking relap se. In one of the few studies of this type, Brandon, Tiffany and Baker (1986) obtained descriptive information in a population of smokers who had participated in a smoking-cessati on program. In this study, subjects were followed for two years. Extensive relapse interviews were conducted at two -week intervals during the first three months following smoking-cessation tre a tme nt , at monthly intervals through one year, and again at 18- and 24-month follow -ups. The prospective study design and frequent assessments helped eliminate self-selection bias and minimized the distorting effects of memory errors and awareness of subsequent smoking. Several interesting findin gs emerged. In 58.5% of the cases, subjects reported the presence of others smokin g prior to their own relapses. Only 2% of the subjec ts were offered the first cigarette they smoked. Thi s finding suggests that there may be little reason to train subjec ts in cigarette refusal skills. Among subj ec ts who smoked a fir st ci garette (slipped), 94.4% smoked a seco nd cigar ette. However, the second cigarette occurred an average of 13 days after the first and only 50% of these subjects smoked their second cigarette on the same day as their firs t. A few basic empirical questions have yet to be answered regarding the natural history of relapse. For example, it has not been determined whether the probability of relap se increases or decreases with time or whether there is a safe point in time beyond which the likelihood of relapse is remote. Moreover, many of the relapse curv es reported in the addiction literature reflect group averages that do not represent what happens to individuals. To better understand smoking relapse, it is important to consider the interaction of individual, environmental, and physio-

DEFINING RELAPSE The description (and measurement) of smoking relapse has turned out to be a major challenge for investigators in this area. Prevalence measures for one or more discrete intervals of smoking versus abstinence provide only a limited picture of the natural history of relapse (Wesson, Havassy & Smith 1986). In the present article, the definitions for various smoking relapse phenomena JOlU1IiJ1 ofPsychoactive Drugs

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tive), and stages of maintenance (i,e., acute, intermediate, protracted or stable) are all differentiated. Biological Determinants. Research on the determinants of smoking relapse has emphasized three types of factors: (1) biological-addiction processes, (2) conditioning factors, and (3) cognitive-social learning variables (Shiffman et al. 1986). In the study of brain mechanisms involved in addictive drug actions, a two-factor model of addiction and smoking relapse has been suggested (Wise 1988). This two-factor model emphasizes (1) the psychomotor stimulant properties of drugs that activate a common neural mechanism of positive reinforcement, and (2) the activation of brain mechanisms that suppress pain and distress signals (negative reinforcement effects). The two-factor model has important implications for the understanding of the development of nicotine addiction and methods for facilitating initial cessation and preventing relapse. It is well known that certain drugs, such as amphetamines and cocaine, have several actions; one of them being to increase synaptic dopamine levels - positive reinforcement effects (Wise 1988). Opioids also activate dopaminergic cells. Nicotine, too, has been shown to have such positive reinforcement effects in the brain (pomerleau & Pomerleau 1984). According to the twofactor model, nicotine cravings (like other drug cravings) result from multiple sources involving memories of past positive and negative reinforcement. Cravings for brain stimulation (positive reinforcement) endure long after poststimulation withdrawal (Pomerleau et a1. 1986). Thus, any drug with psychomotor stimulant actions, including nicotine, may reinstate cravings in individuals who once abused any other drug with these actions. Therefore , according to this model, the use of nicotine may reduce the chances of successful detoxification from other drugs. Stage Theory. The stage theory of behavior change proposed by Prochaska and DiClemente (1986, 1983) has been used to investigate the processes involved in smoking cessation and relapse. Their model includes five stages of change: precontemplation, contemplation, action, maintenance, and relapse. Ten behavior-change processes have been investigated in relation to these five stages: consciousness raising, self-liberation, socialliberation, self-reevaluation, environmental reevaluation, counterconditioning, stimulus control, reinforcement management, dramatic relief, and helping relationships. In one study (Prochaska & DiClemente 1983),longterm quitters were compared with recent quitters, contemplators (i.e., those contemplating quitting), immotives (i.e., those in the preconternplation stage), and relapsers in terms of self-reported behavior change processes. Relapsers and recent quitters reported similar amounts of self-evaluation and stimulus control techniques as well as

logical factors in all stages of the behavior change process. To this end, more descriptive information is needed, using prospective longitudinal research designs and multidimensional assessment methodologies that include both qualitative and quantitative components. Aside from the strength of nicotine addiction, poor long-term treatment outcome is related to the largersocial and cultural context that supports smoking in so many ways and contributes to smoking relapse. However,as social norms continue to change in an antismokingdirection and communitywide approaches take effect, greater treatment gains willlikely be realized. The further study of the natural history of smoking relapse will facilitate this health-promotion endeavor. Theories of Smoking Relapse Relapse Proneness. At the National Working Conference on Smoking Relapse, various models of smoking relapse proneness were introduced (Shiffman et al. 1986). These models all emphasized the dynamics of the relapse process and fluctuations of relapse proneness over time. The "cumulative" model posited that relapse proneness increases or decreases cumulatively over time. In contrast, discrete precipi tous relapse episodes were emphasized in the "episodic" model. The "interactive" model (see Figure 1) combined aspects of the cumulative and episodic models, describing relapse as precipitated by acute events that raise relapse proneness above a certain threshold. More recently, Shiffman (I989a) has suggested that three types of variables influence relapse: (1) enduring personal characteristics, (2) background variables, and (3) precipitants. According to Shiffman, each of these categories of factors is associated with a particular model of relapse proneness. Personal characteristics are associated with a constant-risk model of relapse proneness. Background variables are associated with a cumulativerisk model, and precipitating factors are related to an episodic-risk model of relapse proneness. Such theoretical distinctions become important when designing measurement methodologies or attempting to understand apparent inconsistencies in the smoking relapse literature. For example, self-efficacy is often construed and measured as if it were a stable personal characteristic (i.e., static) rather than dynamic and changing. Shiffman further emphasized the importance of investigating multilevel interactions among relapsepromoting and relapse-protective factors. He proposed an interactive model of relapse in which personal characteristics, background variables, precipitants, and interrelationships among these factors are all considered. In this interactive model, types of coping responses (i.e., stressrelated or temptation-related), stages of coping (i.e., anticipatory, immediate, strategic, responsive or restoraJournal of Psychoactive Drugs

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Relapse

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Precipitant

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Figure 1. The interactive model ofrelapse. Reprinted with permission from: Shiffman, S.; Shumaker, S.A; Abrams, G.A; Cohen, S.; Garvey, A; Grunberg, N.E. & Swan, G.E. 1986. Models of smoking relapse. Health Psychology Vol. 5(Suppl.): 18.

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amples are described below. Abrams and colleagues (1987) developed a series of elaborate laboratory role-play procedures to study the effects of psychosocial stress and coping among smokers who had either quit and remained abstinent or relapsed. In the initial study, four laboratory-based conditions were used: (1) a role -played social skills test, (2) a role-played relapse crisis test, (3) a high-demand social anxiety task, and (4) a relaxation period. Coping responses were assessed and heart rate measures were obtained. The results showed that quitters coped more effectively than relapsers with relapse crisis situations involving negative mood. Quitters did not differ from relapsers in their responses to general social skills or social anxiety tasks. In this roleplaying methodology, the direct observation of the individual 's behavior is not subject to self-report response biases and can provide additional sources of data because smoking is likely precipitated by combinations ofphysiological, cogn itive, behavioral, and environmental factors . Prospective assessment methodologies have been advocated because of the problems associated with retrospective self-report. Because the events assessed by the latter methods are often distant in time from the point of data collection, these data are subject to memory errors and self-presentation distortions. Reports of reactions to smoking temptations or slips may be influenced by the subject's awareness of subsequent smoking. Also, most studies on smoking relapse have involved self-selection biases because subjects have usually been volunteers who come forward to provide information to the investigators. For these reasons, prospective longitudinal analyses of multiple quitting attempts and episodes of smoking relapse are recommended. Swan and Denk (1987) described an "event history analysis" as a method of investigating long-term patterns of abstinence and relapse in ex-smokers. It has been suggested that maintenance is a trial-and-error process for the ex-smoker who learns how to become a permanent exsmoker (e.g., Marlatt & Gordon 1985). This period is often characterized by a series of smoking and nonsmoking states, which is a highly dynamic phenomenon. The event history analysis appears to accommodate both the continuous-time and discrete-state properties of the maintenance process (Tuma & Hannan 1984). Using this type of analysis, Swan and Denk estimated the rates with which men and women relapse and return to abstinence, the frequency of such transitions over time, and factors that influence these transitions. Study subjects were men and women who sought help for smoking cessation. The results showed that 4% of these subjects experienced transitions to relapse each month, and that 8% of the men and 6% of the women returned to abstinence each month. There was no evidence of a "safe point" at which

reliance on helping relationships. Relapsers and contemplators both reported similar levels of consciousness-raising strategies. It was concluded that many of the relapsers may have been attempting to prevent complete relapse by using action-oriented and maintenance strategies to control their current level of smoking. In a subsequent study, Prochaska and DiClemente (1984) showed that most smokers appear to follow a pattern of recycling through relapse experiences several times before they quit smoking permanently. The fact that most people who relapse do not give up and that the average successful quitter recycles through repeated relapse experiences suggests that isolated relapse episodes per se may not be as critical as the way in which the smoker responds to these situations. More recently, Prochaska and colleagues (1988) de veloped a questionnaire to assess the 10 processes of change related to smoking cessation. Both retrospective and prospective methods were used to evaluate the validity of this questionnaire and the relationship between the various processes of change and subjects' smoking cessation efforts. The results of a hierarchical model analysis (see Figure 2) provided further support for the utility of this model in the study of smoking cessation and relapse. Social Learning Theory. Social learning theory (Bandura 1982) has provided the primary theoretical foundation for the study of situational determinants of relapse, the investigation of coping responses, and the development of cognitive-behavioral relapse prevention methods. Social cognitive theory (Bandura 1989) represents a recent derivative of socialleaming theory and appears to be a heuristically promising theoretical model for the study of smoking relapse. Social cognitive theory emphasizes the interaction of cognitive, vicarious, self-reflective , and self-regulatory processes. Self-efficacy beliefs function as an important set of proximal determinants of human motivation, affect, and action. People's beliefs about their ability to exercise control over the events that affect their lives are central to this theory. Such beliefs affect thought patterns, motivation, level of stress (depression, anxiety, arousal), and selection of environments. According to social cognitive theory, human behavior is influenced by goal representations and anticipated outcomes (i.e., outcome expectations). Motivation is seen as self-regulated through proactive and feedback mechanisms. This theory appears to provide an important complement to the biological and conditioning models in explaining tobacco addiction and smoking relapse. Assessment Methodologies A number of recent advances have been made in the development of assessment methodologies and analytical strategies used in the study of smoking relapse. A few ex-

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Figure 2. Standardized estimates of hierarchical model for the processes of change. Reprinted with permission from: Prochaska, J.D.; Velicer,W.E; DiClemente, C.C. & Fava, J. 1988. Measuring processes of change: Applications to the cessation of smoking. Journal ofConsulting and Clinical Psychology Vol. 56: 524.

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more recently, social cognitive theory (Bandura 1989) have provided a comprehensive theoretical framework for the analysis of the psychosocial determinants of smoking relapse. This theoretical model has provided an important framework for examining not only situational variables but also coping responses related to smoking relapse versus continued abstinence. Categorizing Situational Determinants. The study of the determ inants of relapse has become a central concern in the investigation of a variety of addictive disorders (Brownell et aI. 1986b; Marlatt & Gordon 1985 ; Lichtenstein 1982). Several investigators have emphasized situational variables and attributions associated with the first cigarette (i.e., slip) in an attempt to better understand the cues and beliefs that may contribute to relapse. These studies have relied mostly on retrospective self-reports. The findings have generally indicated that relapse is most likely to occur during periods of stress and negative mood -states, although a large number of relapses also occur during enjoyable social events, such as parties and celebrations. These investigations have helped to identify the situations (described below) that need to be addressed during relapse prevention training. Lichtenstein, Antonuccio and Rainwater (1977) reported that over one-third of relapses occurred when the ex-smoker had been drinking alcohol and nearly twothirds occurred when other smokers were present. In Shiffman's subsequent studies (1982) with ex-smokers who called a postsmoking-intervention hotline, negative affect or stress was cited as the major trigger by 52% of hotline callers. Congruent with Cummings, Gordon and Marlatt's findings (1980), nearly one-third of these subjects indicated that other smokers or smoking paraphernalia triggered temptations to relapse (i.e., relapse crises). Most of these relapse crises (60%) occurred with food or alcohol consumption involved. Alcohol consumption appeared to inhibit behavioral coping, which may explain its role in relapse. Two strategies have been used to identify precipitating factors related to smoking relapse: (1) Marlatt's clinical strategy (Marlatt & Gordon 1980), and (2) the objective multivariate approach pioneered by Shiffman (1984,1982). Using their different classification schemes, Marlatt and Gordon (1985) and Shiffman (1982) both found that most temptations to relapse occurred in situations involving negative affect. Marlatt and Gordon (1980) developed a structuredinterview technique and categorization system to describe the relapse situations of alcoholics, heroin addicts, and cigarette smokers . O'Connell and Martin (1987) used this classification scheme to categorize highly tempting situations experienced by 596 participants in smoking-cessation programs at three-month follow-up . A major question addressed in this study was whether or not tempting situ-

time the risk of relapse dropped precipitously. Swan and


Denk concluded that interventions need to be based not

only on factors that decrease the rate of relapse but also on methods that destabilize relapse once it occurs . Fan and Elketroussi (1989) recently described the application of the mathematical model of ideodynamics in attempting to predict recidivism to smoking. Ideodynamics is based on the study of persuasion and the quantification of persuasive messages (i.e., infons) that affect people's behavior. In the case of smoking , there arc external infons (e.g., smoking advertisements and antismoking campaigns) and internal infons or internal pressures to smoke due to the addictive qualities of nicotine. Using these parameters in their model, Fan and Elketroussi calculated accurate time trends for recidivism to smoking among quitters and concluded that the mathematical model of ideodynamics can be a useful analytical tool for modeling addiction and relapse. Such an application of ideodynamics has yet to be replicated. In the investigation of predictors of relapse, reducing heterogeneity is an important way of increasing the power of such analyses. With this in mind, Svanum and McAdoo (1989) examined the prognostic significance of treatment and posttreatment variables on alcohol relapse. To limit heterogeneity in their analysis, they matched relapsers with treatment successes on MMPI scores. Then they classified MMPI profiles as "near normal" or "indicative of psychiatric symptoms." Using this matched-subjects design, they found that emotional turmoil at posttreatment was strongly associated with relapse in the psychiatric group, whereas failure to engage in aftercare plans was related to relapse in the near normal group . They concluded that reducing heterogeneity helped to uncover powerful prognostic indicators of relapse. Such a strategy has potential application in the study of smoking relapse. At the National Working Conference on Smoking Relapse, Ossip-Klein and colleagues (1986) recommended that data analyses should include the use of multivariate analyses. Logistic regressions and other forms of loglinear analyses can estimate the contribution of single variables and their interactions with treatment and with one another. Variables can be considered separately or in sets in a hierarchical fashion . In addition , survival analyses (e.g., Stevens & Hollis 1989) offer an option for determining rates of relapse expressed as a function of time at risk for relapse. In life-table analyses, survival data are summarized by time intervals to describe and evaluate treatment outcome and critical periods for additional treatment or relapse prevention procedures.

SMOKING RELAPSE Situational Analyses Social learning theory (Marlatt & Gordon 1985) and, Journal ofPsyclwacti1le Drugs

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ations that are followed by relapse differ from those followed by continued abstinence. Relapsers were compared with temporary lapsers (i.e., those who smoked but did not resume regular smoking) and complete abstainers. The results showed that relapsers experienced more situations involving withdrawal symptoms and negative affect. Surprisingly, tempting situations involving negative emotions were not frequently reported. Those situations associated with environmental smoking causes were less likely to lead to full-blown relapse. In contrast to Marlatt's clinical approach, Shiffman's multivariate cluster analyses allow for the presence of more than one determinant in a given description of relapse. Using this method, Shiffman, Read and Jarvik (1985) investigated smoking relapse episodes among callers to a smoking-cessation hotline. Cluster analyses revealed that these episodes could be grouped into three categories involving positive affect (i.e., partying, un winding at home, and craving cigarettes) and two categories involving negative affect (i.e., depression and work-related general stress). Ex-smokers who experienced temptations to smoke in party situations were less likely to attempt behavioral coping responses to prevent smoking in those situations. Shiffman and colleagues (1985) concluded that negative affect (stress) plays a significant role in relapse just as it has been shown to influence smoking cessation (e.g., Ikard, Green & Hom 1969). Subsequently, Shiffman (1989a) used a K-means clustering procedure to develop an objective classification of relapse situations. Using this method, he found four categories of relapse situations, including those involving emotional upset, work, social occasions, and relaxation. Again using data from a smoking hotline for newly abstinent ex-smokers, he showed that negative affect was present in both the work and upset categories. The resulting clusters of relapse situations suggested that relapse may be the result of a combination of determinants at any given time (e.g., alcohol, presence of other smokers, and celebration factors occurring simultaneously). Baer and Lichtenstein (1988) examined relapse episodes in a sample of 176 participants in a smokingcessation program who had successfully quit smoking and subsequently relapsed during a 12-month follow-up period. Contrary to previous work, two clusters were derived that described social and nonsocial situations associated with relapse. Their results further indicated that characteristics of relapse situations were not predictable from characteristics of preintervention relapse episodes, prior smoking behavior, stress, nicotine dependence or situation-specific self-efficacy. Situational characteristics of slips prior to full-blown relapse suggested some intraindividual consistency in these slip patterns during abstinence maintenance. Journal of Psychoactive Drugs

Recently, Shiffman's classification methodology has been used to examine relapse crises and coping responses among dieters. Grilo, Shiffman and Wing (1989) classified situational antecedents of dieting relapse crises and dieters' attempts to cope with temptations to overeat. Relapse crises were analyzed in obese subjects with Type II diabetes following the completion of a behavioral weight-control program. Cluster analyses yielded three categories of relapse crises: mealtime, low arousal, and emotional upset Situations involving emotional upset almost always resulted in overeating. Combining cognitive and behavioral coping responses was associated with better outcome. This classification scheme appeared to be remarkably similar to that found for smoking relapse. One important question that needs to be addressed, using these situational analyses, is whether factors that precipitate high-risk situations or relapse crises are differentially associated with subsequent smoking status. Slips and temptation episodes also need further study. For ex ample, it is not known whether there are patterns of such slips (lapses) or close calls that portend future relapse by influencing self-efficacy, as predicted by Marlatt and Gordon's theory (1985). In a recent prospective study of smoking relapse, Baer and colleagues (1989) found that lapses associated with urges and guilt and those occurring in frequent high-risk situations were more likely to result in subsequent relapse. On the other hand, confidence ratings, situational attributions, characteristics of temptations, and number of coping responses were not found to be predictive of subsequent relapse. Another important question regarding the situational analysis of relapse is the degree of consistency across relapse episodes in terms of the characteristics of the situations, coping responses, and outcomes. In a recent study of ex -smokers ' experiences of temptations to smoke, Shiffman (1989b) found only modest transsituational consistency across relapse episodes. Subjects' coping responses tended to vary across situations. Based on these data, Shiffman recommended that rather than designing individually tailored interventions, perhaps the current practice of preparing ex-smokers for all temptation-promoting situations may be the optimal strategy in relapse prevention (e.g., Hall et al. 1984). Self-initiated Smoking Cessation. Because 95 % of attempts to quit are self-initiated, findings from studies of participants in smoking-cessation programs may not be applicable to the majority of smokers attempting to quit. Bliss, Garvey and Heinold (1989) recently conducted a prospective multivariate investigation of relapse among ex-smokers who quit on their own. They sought to examine the effects of relapse crisis precipitants and coping responses on the outcome of th ese relapse temptations during the first month after cessation, and found that the best predictor of continued abstinence was the number of 218

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coping strategies, use of willpower was significantly less effective than other cognitive responses, and self-punitive thoughts were not found to be effective. Other cognitive responses included: positive health consequences, negative health consequences, distracting thoughts, intent to delay, and other self-talk. Shiffman also found that cognitive responses were more frequently used by ex-smokers than behavioral responses in coping with temptations to smoke. His overall findings indicated that coping responses helped maintain abstinence no matter what type of coping response was used. Shiffman concluded that it is probably most useful to teach ex-smokers a broad repertoire of coping responses and to identify factors that help overcome inhibitions in the use of such coping responses. Withdrawal Symptoms. Most experts agree that relapse occurring during the first few days following cessation is often attributable to nicotine cravings and other acute withdrawal symptoms (O'Connell & Martin 1987). Biological-addiction models of habitual cigarette smoking emphasize the development of drug tolerance and withdrawal in the maintenance of the smoking habit and relapse. West and Russell (1988) studied acute (i.e., 24 hours of abstinence) withdrawal symptoms in 21 smokers. Cardiovascular and subjective symptoms were measured. Their results suggested that the severity of withdrawal symptoms was associated with the loss of acute tolerance to nicotine. These investigators speculated that this finding could be due to more rapid nicotine clearance or constitutional factors in nicotine sensitivity. They found no evidence to support the view that higher chronic tolerance was associated with more severe withdrawal symptoms. On the other hand, smokers who lose acute tolerance more quickly may suffer more severe withdrawal symptoms . Alternatively, a greater sensitivity to nicotine in the absence of acute tolerance or a lower degree of chronic tolerance could contribute to more severe withdrawal symptoms. Hatsukami and colleagues (1988) studied acute withdrawal symptoms associated with partial versus total smoking cessation. Significant partial versus total cessation differences were found only for heart rate changes, weight gain, awakenings from sleep, and anger. Future studies are needed to examine the long-term effects of partial versus total cessation over several weeks.

coping strategies used. In contrast to Shiffman's previous findings (l986b, 1984, 1982) with smoking-cessation participants, using combinations of cognitive and behavioral coping strategies was not more effective than using cognitive or behavioral strategies alone. During the second half of the one-month follow-up period, the presence of other smokers resulted in an increased likelihood of smoking. Coping was associated with resisting the temptation to relapse, but no single coping strategy was more effective than any other in preventing relapse. The findings of this study also indicated that baseline motivation to quit and the presence of other smokers during relapsecrisis (i.e., temptation) situations were related to coping and outcome. In contrast to O'Connell and Martin (1987), outcome was not related to the presence of withdrawal symptoms. Marlatt, Curry and Gordon (1988) conducted a longitudinal analysis of unaided smoking cessation over a two-year period. They found that those variables that were associated with short-term outcome were not the same as those related to long-term outcome. The use of multiple cessation strategies was associated with abstinence at two years. A strong motivation to quit was found to be related to both initial success and long-term abstinence maintenance. Cohen and colleagues (1989) recently reported data from 10 major prospective studies of self-quitting. Success rates for self-quitters were not found to be any better than those for treatment programs when a single attempt was evaluated. Surprisingly, there was little relationship between previous attempts to quit and the probability of current success. These data supported the notion that quitting smoking is a dynamic process rather than a discrete event and that most people cycle from smoking to nonsmoking repeatedly. Future studies were encouraged that track smoking and quitting prospectively for several years. Role of Coping Responses. Situational analyses of smoking relapse have focused not only on characteristics of the situation but also on the individual's response to that situation. In the investigation of responses to temptations to smoke, any response that prevents relapse is referred to as a coping response. Coping responses have been categorized as either behavioral or cognitive. Shiffman (1984) studied the effectiveness of cognitive and behavioral responses and cross-validated earlier fmdings on callers to a smolcing-cessation hotline. In contrast to the findings for self-initiated smoking cessation, he found that combining cognitive and behavioral responses enhanced effectiveness. Seven types of behavioral coping were equally effective in preventing relapse: eating/drinking, engaging in a distracting activity, escape, delay, engaging in a physical activity, relaxing, and engaging in any other behavior. In the category of cognitive Journal ofPsychoactive Drugs

Factors Related to Smoking Relapse Traditionally, the smoking-cessation treatment outcome literature emphasized the investigation of psychosocial factors related to long-term maintenance of abstinence following smoking-cessation treatment. For example, in a recent study by Mothersill, McDowell and Rossner (1988), several factors were found to be related 219

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to long-term abstinence, including stronger beliefs in being able to quit either with or without treatment, smoking for fewer years, lighter smoking, being less governed by habit and need for stimulation in smoking, having quit for longer periods during previous attempts to quit and during the longest period of previous abstinence, and having smoked less on weekdays than on weekends. Thus, in this prospective study, variables reflecting past smoking behavior, reasons for smoking, and self-efficacy expectations regarding quitting were all associated with long term abstinence. With the advent of an increased emphas is on relapse prevention during the past decade, there has been a rapid grow th of em pi rical research attempting to identify factors related to relapse, such as stress, social support, weight gain, and conditioning factors. In the followin g sections, each of these factors will be examined in greater detai l. Neg ative Mood States (Stress). Numerous investigations have implicated stress (negative affect) as one of the primary obstacles to the successful maintenance of abstinence among ex-smokers (Carmody 1989; Mermelstein 1985; Cohen, Kamarck & Mermelstein 1983; Benfari et al. 1982) . Other studies have shown that anxious, de pressed, and neurotic individuals have more difficulty than other ex-smokers maintaining abstinence (e.g., McCrae, Costa & Bosse 1978; Bergler 1976; Jacobs 1972). Moreover, stress has been consistently shown to be the most common factor triggering relapse (Abrams et al. 1987; Brandon, Tiffany & Baker 1986; Shiffman 1986a, 1986b, 1982; Curry, Marlatt & Gordon 1985; Shiffman et al. 1985; Shiffman, Read & Jarvik 1985; Ocken e et al. 1982). In Shiffman's (1986b, 1982) series ofretrospective survey studies of ex-smokers who contacted a smoking relapse hotline, stress (negative affect) was cited as a precipitant of relapse by a majority of ex-smokers. Specifically, frustration and anger triggered relapse in over 50% of the cases, whereas depression was associated with 20% of relapse crises. In the cluster analyses conducted by Shiffman and colleagues (1986b) described above, two categories ofrelapse situations involved negative affect high arousal and low aro usal (Shiffman, Read & Jarvik 1985). Higharousal situations typically occurred at work where subjects felt pressured, frustrated or anxious. In low-arousal situations, subjects were usually at home and felt bored or depressed. Approximately 70% of relapse crises (i.e., situation s increasing the temptation to slip or relapse) occurred in situations involving negative affect. Whereas 43 % of the subjects indicated that they were typically seeking to reduce tension on those occasions when they were most tempted to smoke , only 20% reported that they were trying to satisfy cigarette cravings. Journal a/ Psychoactive Drugs

In cue reactivi ty studies (desc ribed below), negative mood-states (e.g., anxiety) have been investigated in relation to exposure to smoking cu es and relapse (e.g. , Abrams et al. 1988). Unfortunately, in these studies, it has been difficult for the investigators to distinguish between negative affecti ve states and cravings beca use these two factors interact as components of nicotin e withdrawal. The task of separating negative mood from other conditioned drug withdrawal reactions poses a formidable challenge in the study of smoking relapse. In studies exam ining the rela tionship between de pression and smoki ng ce ssation and relapse, it has recently been shown that depressed individuals report more withdrawal symptoms while attempting to qu it and are more likely to resume smoki ng following treatment when compared to nondepressed smokers (Hall 1988). One explanation of this relationship between depre ssion and relapse might be the ne uroendoc ri ne dysregulation associated with nicotine withdrawal (pomerleau 1986). Prolonged dysregulation of neuroendocrine function may contribute to depressed mood as well as to dysphoria-related relapse (Hall 1988; Hugh es 1988; Pomerleau 1986; Balfour 1982). Alternativel y, certain characteristics, such as low self-esteem, may predispose smokers to both depression and smoking. Furthermo re, some smokers may use nicotine to self-medic ate thei r depressed mood (Hughes 1988). In examining the relationship between depr ession and relapse, investigators have studied both the history of depress ion and current depressed mood . Both of these variables have been found to be related to failur e in quitting smoking and maintaining abstinence (e.g., Glassman ct al. 1988). Hughes has suggested that smokers with a history of depression, irrespective of current mood , may use nicotine to prevent the recurre nce of depressive episodes. Alternatively, they may lack the soc ial or assertiveness skill s necessary to effecti vely deal with relapse-risk situations. The relation ship between depressed mood, history of depression, smoking cessation , and relapse certainly seems deserving of further study. Conditioning Fact ors an d Relapse . According to Niau ra and colleagues (1988), several learning-related factors have been investigated in relation to drug relapse, including conditioned withdra wal, conditioned compensatory respond ing, appetitiv e motivational processes, and socialleaming variables. Conditioning factor s are central to all but the latter theoretical model. Studies of these conditioning factors evaluate reaction s to cues associated with prior drug ingestion in orde r to better understand the relevance of these cues to relap se. Soc ial learning theory, in contrast to the conditioning theories, emph asizes the relationship between cognitive reactions to smoking cues, coping respon ses, and relapse. The various conditioning theories of smoking behav220

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coping responses were less effective in preventing relapse than the responses of nonsmokers, although these two groups did not differ in general social competence. As suggested by these studies, cue reactivity prior to treatment or at the end of treatment may be related to relapse, but further research is needed to confirm this relationship. Using this same CUET procedure, Abrams and colleagues (1988) conducted two additional studies of the psychophysiological, behavioral, and cognitive responses of participants. In one study, relapsers were compared with long-term quitters and never-smokers (controls). Relapsers had significantly higher anxiety and stronger urges to smoke in the CUET than either quitters or controls. In addition, they showed greater heartrate reactivity and were rated as having less effective coping skills than controls. In the second study, responses in the CUET were found to predict smoking status at six-month followup. Those subjects with significantly less heart rate reactivity at baseline were more likely to be quitters at six months . In another study using the CUET procedure, Niaura and colleagues (1989) found that only increased heart rate at pretreatment was predictive of smoking status at sixmonth follow-up when posttreatment smoking rate was controlled . In addition, both pre- and posttreatment smoking rates were predictive of smoking status at six months. It was hypothesized that heart rate may reflect the strength of conditioned reactions to smoking-relevant stimuli . These researchers encouraged the further exploration of the bioinformation-processing paradigm - discussed by Baker, Morse and Sherman (1987) - in explaining the meaning of such physiological indices as heart rate reactivity in relation to conditioning and cognitive/affective factors in the development and maintenance of smoking urges. Unfortunately, most of the available information about the hypothesized unconditioned effects of nicotine on human psychophysiological responses has been derived from experienced smokers rather than naive subjects. The observable responses of an experienced smoker represent a mixture of unconditioned and conditioned reactions. Nonetheless, these studies using the CUET procedure have suggested that conditioning factors play an important role in smoking relapse. Causal Attributions. It has been shown that smokers attempting to quit smoking typically make attributions regarding factors related to the outcome of their effort. Such causal attributions have been shown to influence long-term abstinence (e.g., Harackiewicz et al. 1987; Goldstein, Gordon & Marlatt 1984). The way in which treatment procedures are presented can influence these attributions. For example, a treatment using nicotine gum might foster external attributions for success/failure (i.e., environmental factors) . In contrast, a self-administered

ior and relapse emphasize the influence of the context of drug administration and conditioning factors in explaining withdrawal symptoms and relapse (Stewart, deWit & Eikelboom 1984; Siegal 1983; Wikler 1965). Over two decades ago, Willer hypothesized that interoceptive stimuli, such as certain affective states, may produce neurophysiological changes resembling drug effects that then become conditioned stimuli triggering cravings, with drawal , and relapse after repeated pairings with the drug effects. Niaura and colleagues (1988) have developed the dynamic regulatory feedback model to examine the role of affective and contextual cues in the maintenance of substance use/abuse and relapse. According to this model (see Figure 3), positive or negative affective responses interact with cognitive and behavioral factors, which in turn are paired repeatedly with substance use/drug effects, and thereby become conditioned stimuli triggering further drug use. According to all of the conditioning models of addiction, both exteroceptive and interoceptive cues (i.e., antecedent stimuli, such as the sight and smell of cigarette smoke) can elicit conditioned drug-specific responses. These conditioned responses involve physiological, behavioral, and affective reactions similar to those observed during acute drug withdrawal and are counterdirectional to initial appetitive drug effects. According to this model, the transition from abstinence to initial drug use (i.e., lapse) is postulated to be a direct function of the strength of these conditioned responses. Smokers' reactions to substance cue exposure and the relationship between these reactions and relapse have been investigated in both clinical and laboratory studies using an assessment methodology referred to as the Cue Exposure Trial (CUET) (e.g., Abrams et al. 1988). The results of these studies have shown that the urge to smoke is increased among addicted individuals by the presence of physical cues associated with smoking as well as by negative and positive affective states and even small doses of nicotine. In other words, smokers do show increased cravings and psychophysiological reactivity to smoking cues when compared to nonsmokers. In a recent survey of four of these studies, Niaura and colleagues (1988) reported physiological responses to smoking cues (i.e., increases in heart rate, vasoconstriction, and blood pressure) that were suggestive of increases in generalized arousal. They concluded that the psychophysiological (arousal) effects of even small doses of nicotine may be due to expectancies for drug effects. In addition, withdrawal states appeared to be infrequently associated with urges to use tobacco or to relapse. Abrams and colleagues (1987) attempted to determine whether or not the coping responses of recent relapsers are disrupted by cue exposure. They showed that when relapsers were presented with smoking cues, their Journal ofPsychoactive Drugs

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. ~

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Figure3. Diagram of a dynamic regulatory feedback system linking constructs related to relapse. Unidirectional arrows indi -

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ATTAIBUTlOHS

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cate direction of influence. Positive/negative signs indicate whether influence is excitatory or inhibitory. Bidirectional arrows indicate reciprocal interdependence. Reprinted with permission from: Niaura, R.S. ; Rohsenow, OJ.; Binkoff, I.A.; Monti, P.M.; Pedraza, M . & Abrams, D.B . 1988. Relevance of cue reactivity to understanding alcohol and smoking relapse. Journal ofAbnormal

NEQATTVE AFFECT

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Until recently, studies of the causes of postcessation weight gain in ex-smokers were lacking, primarily due to methodological difficulties. In one study (Hall, Ginsberg & Jones 1985), weight changes occurred within three weeks of quitting smoking and continued for six months. Intake of total calories, fat, and sucrose increased after the quit date . Furthermore, increased caloric intake predicted subsequent weight gain 26 weeks later for women but not for men. Interestingly, mean caloric intake was lower at 26 weeks than at baseline. These researchers postulated that ex-smokers may reach a new equilibrium point in body weight several weeks after quitting. Concomitantly, food consumption may decrease because increased food intake is no longer prompted by biological factors related to weight gain. Alternatively, Hall, Ginsberg and Jones speculated that ex-smokers may become less focused on withdrawal symptoms six months after quitting and may therefore be better able to address the task of controlling their weight. Rodin (1987) studied weight fluctuations in middleaged smokers before, during, and after their participation in various smoking-cessation treatments. She found that ex-smokers who gained weight after quitting did not consume more total calories but ate less protein and more carbohydrates than quitters who showed no weight change or lost weight. In addition, quitters showed an increased preference for sweet taste whether or not they gained weight Gain in body weight was associated with postcessation intake of sweets, but not preference for sweets. Also, subjects who gained weight after quitting engaged in less aerobic activity. Rodin's results showed that only some people gain weight after quitting smoking and that several predisposing, metabolic, and lifestyle factors determine postcessation weight trends. Hall and colleagues (1989) recently compared dietary patterns, physical activity, and weight trends in subjects who continued to smoke versus those who had quit or had greatly reduced their smoking rates. Changes in intake of total calories, total sugar, sucrose, fat, protein, and nonsugar carbohydrates, and changes in physical activity levels were evaluated at two, 12, and 26 weeks after initial cessation. The results indicated significant increases in the intake of calories, sucrose, and fat at two weeks postcessation. Activity levels did not change significantly. Further studies are needed to examine whether the controlling dietary factor in posteessation weight gain is the sweetness or fatness quality of food. For example, it is not known whether there is a single underlying mechanism leading to increased preference for sweet and/or fatty foods and related weight gain . Social Support. A number of studies have examined the role of social support in smoking cessation, maintenance of long-term abstinence, and relapse. The relation-

behavioral program may foster internal attributions for success (i.e., the characteristics of the smoker). Harackiewicz and colleagues studied the relationship between such causal attributions and smoking cessation and maintenance by varying the "externality" of treatment (i.e., extent to which success or failure would be attributed to treatment procedures as opposed to participant characteristics). In a 2x2 experimental design, treatment procedures (self-help versus nicotine gum) and motivational orientation (internal versus external) were varied. The results provided evidence that causal attributions affect outcome, both in terms of initial cessation and maintenance. Specifically, ex -smokers tended to take more credit for their success and smokers blamed external factors for their failure to quit Attributions varied according to both condition and outcome. Contrary to the investigators' predictions, external attributions proved beneficial for maintenance in both nicotine gum conditions, which likely reflected the level of confidence that smokers placed in their doctors and the potency of drug treatment. These researchers concluded that experimental attempts to focus subjects' attention on intrinsic or internal factors may only be effective when this information is consistent with the degree of internality inherent in the treatment procedures. An important direction for future research will be to determine the relationship between causal attributions and various coping behaviors of successful quitters trying to remain abstinent Commitment to Abstinence. Another important variable related to sustained abstinence versus relapse is the level of commitment to abstinence. In this regard, Hall and Havassy (1986) developed a model of relapse that emphasizes commitment, withdrawal symptoms (including negative affect), and environmental support as determinants of relapse. In a study designed to test this model, Hall and Havassy predicted an interaction effect of commitment and negative mood on relapse, and found that individuals who expressed greater commitment to abstinence were slower to relapse. Unfortunately, they were unable to detect an interaction effect for commitment and negative mood because of the small number of subjects in their study. They concluded that several dimensions of commitment to abstinence must be considered, including desire for abstinence and perceived probability of success. Weight Gain. Quitting smoking results in weight gain for many smokers and is likely a cause of relapse for some ex-smokers. The relationship between weight gain and relapse is complex. Postcessation weight gain could be a result of reduced energy use and/or increased caloric intake . Energy use mechanisms possibly involved in this weight gain may include decreased basal metabolic rate, decreased thermogenesis or decreased physical exercise because of withdrawal-related fatigue (Hall et al. 1989). Journal of Psychoactive Drugs

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ship between social support and long-term abstinence has been shown to be quite complex, depending on the specific form of social support and stage of behavior change. In one study, Mermelstein, Lichtenstein and McIntyre (1983) found that successful abstainers reported that they received more support from their partner than smokers who never quit or those who quit and subsequently relapsed. Similarly, Coppotelli and Orleans (1985) found that successful women abstainers had higher levels of perceived spousal support, both generally and with regard to smoking. In a related study, Mermelstein and colleagues (1986) assessed the effects of three social support factors on smoking cessation and maintenance: (1) partner support directly related to the quitting effort, (2) perceptions of the availability of general nonsmoking social support resources, and (3) the presence of smokers in the individual's social network . All three of these social support factors were found to playa significant role in smoking cessation/maintenance, but at different points in time following initial cessation. Partner support and perceived availability of general support were both associated with initial cessation and short-term (i.e., three-month) maintenance of abstinence. The presence of other smokers in ex-smokers' social networks was negatively associated with maintenance, and significantly differentiated relapsers from abstainers at 12-month follow-up. These findings suggest that it may be useful to examine the effects of social support on smoking cessation and relapse in terms of at least three distinct phases: (1) initial cessation, (2) short-term maintenance (i.e., up to three months), and (3) long-term maintenance. Several hypotheses have been proposed to explain the effects of social support on the maintenance of longterm abstinence. According to one hypothesis, social support may help buffer the ex-smoker from the negative effects of stress on the maintenance of abstinence (Cohen & Wills 1985; Shiffman 1982). Social support may also help to create a more manageable environment by reducing daily hassles, stress or negative emotions that might otherwise overtax an individual's coping abilities, thus predisposing that person to relapse (Coppotelli & Orleans 1985) . Alternatively, social support can affect behavior change either indirectly through mediating variables or directly through its influence on the desired (target) behavior. On the other hand, as shown in one study (Caplan, Cobb & French 1975), some forms of social support can be a hindrance rather than an asset. For example, having significant others who smoke has been shown to be associated with an increased risk of relapse (West et al. 1977). Individual differences need to be assessed to permit better matching of intervention procedures with smokers' needs pertaining to social support. Future studies are needed to investigate sex differences, the effects of the Journal a/Psychoactive Drugs

stage of behavior change, and various dimensions of social support in relation to smoking cessation and long-term abstinence . The role of social support in larger environmental, organizational, community, and worksite settings also should be examined, and family or dyadic interpersonal relationships need to be investigated as well as larger systems at the organizational and community levels.

RELAPSE PREVENTION INTERVENTIONS The traditional approach to facilitating long-term maintenance of abstinence has been to extend treatment by using so-called booster sessions and monitoring long-term maintenance at follow-up assessments (e.g., Powell & McCann 1981). Based primarily on the pioneering work of Marlatt at the University of Washington and Shiffman at the University of Pittsburgh and their colleagues, the more recent approach has been to emphasize the prevention of smoking relapse by using intervention procedures that correspond to the natural history of lapses and relapse episodes. Most of these relapse prevention interventions are based on social learning theory (Marlatt & Gordon 1985) and social cognitive theory (Bandura 1989). Various approaches to relapse prevention have been investigated, including motivation enhancement, social support, coping skills training, reinforcement, lifestyle balancing, and even the use of various pharmacological agents. Short-term maintenance procedures have emphasized social support, reinforcement, coping skills training, and use of pharmacological agents , whereas long -term maintenance has focused on the monitoring of temptations to smoke, preparation of nonsmoking responses to these high-risk situations, initiation of general lifestyle changes, systematically graded smoking-cue exposure, stress management, and weight control. Brown ell and colleagues (1986b) developed a list of research needs in relapse prevention (see Table 1). Since that time, considerable research has been conducted on intervention procedures designed to prevent smoking relapse. Brownell and colleagues (1986a) postulated that relapse prevention strategies should be initiated during the early stages of behavior change (i.e., preparation phase of quitting smoking). These experts asserted that certain relapse prevention procedures may be more appropriate than others at particular stages of behavior change, and concluded that no single model of relapse prevention appears to be adequate to direct all future intervention research . Indeed, more recent treatment outcome research on smoking relapse prevention has shown them to be correct on this last point.

Maintaining Long-term Abstinence In the past decade, an increasing number of treatment 224

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TABLE I RESEARCH NEEDS IN THE AREAS OF LAPSE AND RELAPSEAreas

Natural history

Ouesnons 10 be answered

1 . Is a relapse incremental learning or a

failure experience?

2. Does the chance of relapse increase or decrease with time?

3. What are the stages of the lapse and relapse processes? 4 . Is there a " safe" point beyond which a person will not relapse? 5. How frequent are lapses, and do they precede relapse?


Effects of lapse and relapse

1. What are the effects on mood?

2. Do lapse and relapse influence selfefficacy?

3. Do others' reactions influence lapse and relapse? 4 . What are the physiological effects of lapse and relapse? 5 . How do professionals deal with relapse in their patients? Determinants and predictors

1. Do various treatments influence

probability of relapse?

2. Does 'earty response to treatment predict relapse?

3. Is past history of success and relapse predictive? 4 . What are the roles of withdrawal symptoms, cravings. and urges? 5. What are the roles of conditioning and compensatory responses? 6. What are the mechanisms of social support? 7 . Do physiological factors influence risk? 8. Can relapse be predicted after treatment but before maintenance? Prevention of lapse and relapse

1. What criteria can be used to screen patients? 2. Does screening influence false positive and false negative rates? 3 . What is the role of exercise? 4 . Are cue extinction procedures helpful? 5. Is there any role for programmed relapse? 6. What are the relevant coping strategies? 7. Can motivation be enhanced at various points in treatment? 8 . Is lifelong treatment necessary?

*Reprinted with pennission from : Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E. & WlIson, G.T. 1986. Understanding and preventing relapse. A~ricall

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outcome studies have investigated the maintenance of long-term behavior change following treatment for alcohol, heroin, and nicotine addiction. One of the largest investigations of maintenance interventions to date in the smoking cessation literature evaluated the American Lung Association's self-help cessation and maintenance manuals (Davis, Faust & Ordentlich 1984). This maintenance intervention also included recorded motivational phone messages used over a two-month period. The results indicated that subjects who received the maintenance manual had significantly higher abstinence rates than subjects who only received smoking-cessation materials that did not emphasize behavior change techniques. In a study designed to test the effects of various treatment components representing different stages of treatment (e.g., preparation, maintenance), Lando (1982) assigned smokers to one of seven treatment conditions. The results showed that individual treatment elements did not produce significantly different outcomes and that maintenance booster sessions did not appear to be helpful in reducing or preventing relapse. Lando concluded that such attempts to isolate the effects of precise treatment components on long-term abstinence are unlikely to be successful, particularly with relatively small samples of smokers . In a subsequent study, Lando and McGovern (1985) compared three maintenance procedures (oversmoking, nicotine fading, and nicotine fading/smoke-holding) with a no-maintenance control. Oversmoking and smokeholding arc two aversive procedures in which the smoker is instructed to either take long puffs without inhaling or simply to hold the smoke in his or her mouth for several seconds. The dual purpose of this study was to test the effects of nicotine fading as an alternative to oversmoking in a multicomponent or "broad-spectrum" treatment and to assess the effectiveness of oversmoking as an unpleasant yet relatively safe aversive treatment procedure. The intensive maintenance treatment failed to strengthen the effects of nicotine fading in preventing relapse. At 12 months, between-group differences were negligible. Moreover, considerable relapse occurred in each of the treatment conditions. Glasgow and Lichtenstein (1987) reviewed 60 studies that included a minimum of 12 months of follow-up data. They concluded that behavioral approaches appeared to be superior to control conditions but no more effective than alternative treatment, Programs combining skills training with nicotine gum appeared to be more effective than component strategies used alone. Intensive treatments, particularly those using aversive procedures, yielded impressive initial results, but relapse was typically substantial. Behavioral procedures appeared to be less effective with heavy smokers (e.g., one pack per day) in preventing relapse. These authors concluded that in Journal ofPsychoactive Drugs

order to produce long-term results, an intervention must yield greater initial cessation rates and must include relapse prevention procedures capable of assisting a high percentage of quitters. Whereas some outcome studies have shown a beneficial effect of behavioral maintenance interventions, other studies have failed to find such an effect Inadequate sample size has been a major culprit in these latter studies. In addition, maintenance procedures have not always reflected the model that they were designed to test or may not have been implemented correctly. Cognitive-Behavioral Relapse Prevention Based on social learning theory and the more recent social cognitive theory (Bandura 1989), cognitive-behavioral approaches to relapse prevention typically have two central components: (1) a situational focus, and (2) an emphasis on coping skills training (Annis 1986; Litman 1986). In cognitive-behavioral relapse prevention training, coping skills refer to any attempt to respond to the temptation to smoke in any way other than smoking. Typically, such coping skills have been divided into two categories: cognitive and behavioral. Marlatt's Relapse Prevention Model. Marlatt's cognitive-behavioral relapse prevention model (Marlatt & Gordon 1985) has been most influential in the development of relapse prevention training procedures (e.g ., Chancy, O'Leary & Marlatt 1978). Marlatt's approach emphasizes the importance of anticipating and developing strategies for coping with temptations to slip or relapse so that a high level of self-efficacy can be maintained for warding off such temptations in the future. If a slip or lapse occurs, participants are trained to avoid selfdefeating attributions and associated negative emotional states (c.g., guilt), which Marlatt refers to as the Abstinence Violation Effect (AVE). The AVE is assumed to increase the probability of full-blown relapse. Studies of Marlatt's cognitive-behavioral relapse prevention methods (e.g., Marlatt, Curry & Gordon 1986) have yielded mixed results at best. Relapse prevention strategies based on Marlatt's cognitive-behavioral model have not been shown to consistently enhance maintenance of long-term abstinence. Brown and colleagues (1984) reported that a combined nicotine-fading/relapse-prevention program resulted in a 46% abstinence rate at six-month follow-up. In nicotine fading, smokers gradually reduce their dosage of nicotine intake by switching brands and reducing the number of cigarettes smoked before quitting completely. This multicomponent program was compared to two other conditions receiving either nicotine fading or relapse prevention alone. Marlatt's model was used in the relapse prevention intervention. No overall betweengroup differences in abstinence rates were found at one226

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relapse to occur, situational cues and the cravings they trigger must overwhelm the ex-smoker's ability to cope or to resist the urge to smoke. Shiffman's cognitive-behavioral approach to relapse prevention, like Marlatt's approach, emphasizes education, assessment, and coping-skills training. In the educational component, realistic expectations about quitting smoking and maintaining abstinence are encouraged. The assessment procedures are designed to determine highrisk situations and deficiencies in coping responses. Skills training serves to remediate coping response deficiencies. An important initial educational step in this approach to relapse prevention often involves reorienting the exsmoker 's attitudes about quitting smoking. Many smokers expect a successful quitting effort to be free of struggle and are disappointed when they encounter difficulties. More realistic expectations can facilitate the ma intenance of abstinence. This initial education in volves dispelling the ex-smoker's myths about smoking cessation. Several assessment methods have been developed to evaluate situations likely to be associated with the threat of relapse. Shiffman and colleagues (1985) developed the Smoking Occasions Questionnaire to assess such situations. Factor analyses indicated seven relapse-temptation factors derived from this instrument: (1) negative affect, (2) positive affect, (3) boredom, (4) social situations, (5) food substitute, (6) alcohol, and (7) eating. This instrument reflects the overlap between the classification systems of Shiffman, Marlatt and Lichtenstein, who have each conducted extensive studies of smoking relapse situations, which were reviewed earlier in this article. Because relapse is thought to occur at the intersection of high-risk situations and coping-skill deficits in Shiffman's cognitive-behavioral model, additional assessment instruments have been developed to measure coping skills (both cognitive and behavioral). One such measure is the Coping Response Survey (Shiffman et al. 1985); another is the Smoking Situational Competency Test, which was developed to assess cop ing skills related to temptations to relapse, using role-play analogues. Using these assessment methodologies, coping-skill deficits can be identified so that the ex-smoker 's repertoire of coping skills can be expanded, including imagery, self-talk, relaxation techniques, physical activity, alternative consummatory behavior, and assertiveness skills. In Shiffman's cognitive-behavioral relapse prevention training, efforts are made to tailor specific coping skills to specific high-risk situations. Ex-smokers are counseled on how to deal with slips and temptations to relapse. A debriefmg procedure is sometimes used to identify and discuss incidents in which the ex-smoker is confronted by temptations to relapse. Self-efficacy in Relapse Prevention. Two important

year follow-up. Brown and colleagues concluded that their interventions were too complex. Glasgow and colleagues (1985) conducted a 2.5 year follow-up on smokers (N=48) who completed a behavioral smoking cessation treatment that included relapse prevention training based on Marlatt's model. However, the percentage of smokers who quit smoking following the initial intervention was too small to effectively evaluate the effects of relapse prevention training. Davis and Glaros (1986) studied the effects of a multicomponent relapse prevention treatment based on Marlatt's cognitive-behavioral model of the relapse process. They used the behavior-analytic method (Goldfried & D'Zurilla 1969) to develop assessment instruments to identify training situations and target coping responses. Two maintenance conditions were compared: (1) relapse prevention training, and (2) a discussion control. Subjects in the former condition received training in problem-solving and social skills needed to cope with temptations to relapse. Maintenance of abstinence was positively related to competence in coping with temptations to smoke. However, coping skills were not maintained during the follow-up period. Stevens and Hollis (1989) recently described a relapse prevention intervention in which an individually tailored skills-training technique was used. They compared this skills-training approach with a discussion condition and a no-treatment control group. A survival analysis indicated an abstinence rate of 41.3% for the skills-training group at one year, compared to 34.1 % for the discussion group and 33.3% for the no-treatment control condition. All subjects attended an intensive initial smoking-cessation program in which they were taught over 40 cognitive and behavioral smoking-cessation techniques . In the skills-training procedure, cognitive and behavioral alternatives to smoking were identified and rehearsed. Specific high-risk situations were identified for each participant, following Marlatt's model. Data indicated that the content rather than the number of maintenance sessions was important and supported the usefulness of Marlatt's relapse prevention intervention model. Stevens and Hollis argued that other studies that have failed to demonstrate the utility of Marlatt's methods have not had adequate sample sizes and therefore the statistical power to show the superiority of these relapse prevention procedures. Shiffman's Relapse Prevention Model. In Shiffman's approach, relapse versus continued abstinence is thought to be determined by an interaction between characteristics of the tempting situation and characteristics of the exsmoker in responding to that temptation. According to this view, no situation per se is sufficient to cause relapse. Similarly, attempts to identify traits associated with backsliding have failed. According to Shiffman, in order for Journal ofPsyc1uxu:tive Drugs

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Preventing Rela pse In Nicotine Addiction

concepts in both Shiffman's and Marlatt's cognitive-behavioral approaches to relapse prevention are self-man agement (self-regulation or self-control training in which ex-smokers are taught how to regulate their own behavior and lifestyles to prevent relapse) and self-efficacy expectations (e.g., Condiotte & Lichtenstein 1981). Self-efficacy is a cen tral psychological construct in Bandura's (1989) social cognitive theory. It is also a core concept in Marlatt's model of relapse prevention. According to Marlatt, successful coping with temptations to smoke en hances the ex-smoke r 's self-efficacy for maintaining ab stinence, whereas relapse episodes diminish self-efficacy and precipitate an AVE that increases the chances of further slips and eventual relapse. For the ex-smoker who over comes the temptation to smoke, learns from it, re solves to continue efforts to remain abstinent, and feels more confident about such efforts, continued abstinence is more likely. If, on the other hand, the AVE occurs, feel ings of guilt and incompetence also emerge, further indul gence may be more easily justified, and relapse is more likely to res ult. Marlatt (1978) hypothesized that the feeling of bein g out of control following a lapse or slip may trigger fullblown relapse. This hypothesis became the rationale for the use of "progr am med relapse" (i.e., providing the exsmoker with an opportunity to experience a controlled lapse in order to help prevent the AVE). However, the effectiven ess of this particul ar procedure has yet to be empiri cally confirmed. DiClemente, Pr oc haska and Gibertini (1985) al so ex am ined self-efficacy in the self-change of smoking behavior. In thi s study, efficac y expectations at baseline were found to be associated with c hanges in smoking status for rec ent quitters and contemplators. Subjects in cluded five groups that represented the different stages of self-change (i.e., immotives, contemplators, recent quittcrs.Iong-term quitters, and relapsers). In both cross-sec tional and longitudinal analyses, cue strength (temptation level) an d self-efficacy (confidence) were assessed. Selfeffi cacy expectations were found to be highly related to maintenance of abstinence and movement through the stages of c hange for contemplators and recent quitters . Self-efficacy expec tations were also related to smoking cessation and maintenance ac tivities. Lifestyle Balancing. Lifestyle-balancing interventions are another important part of cognitive-behavioral approach es to relapse prevention training. Essentially, this component of relapse prevention involves helping the ex-smoker to meet basic needs that cigarettes served to meet, needs that were associated with cravings to smoke. Typicall y, these lifestyle-balancing interventions involve teaching the ex-smoker alternative ways of coping with stress and sub stituting other forms of enjoyment in place of smoking. Recently, enthusiasm for these lifestyle mod J OUTNJ/

ofPsychoactive Drugs

ification proc edures has been dampened by ou tcom e data sugges ting ex treme difficulty in prompting people to ad here to long-term regimens related to fitness, diet, med ication, and smoking cessation. Non eth eless, the concept of life style balancin g appears to fit we ll withi n the cognitive-behavioral or soc ial learning mo del of relap se preve ntion and continues to be em p loyed in re la ps e prevention resear ch. Socia l-Skills Training. Soc ial-ski lls training has become a nother imp ortant component o f social-learningbased relapse prevention training. In social-skills training, ex -smokers are taug ht how to dea l effectively with a variety of interpe rson al situations associated ei ther directly or indirec tly with the risk of smoking relapse (e.g., refusal and avoidance skills , assertive ness) . Mo st of the e mpiri cal research has focused on the application of social-skil ls train in g in th e trea tment of oth er forms of substa nce abuse (e.g. , alcohol dependenc e). Monti and colleagues (1986) described the role of social-skills training in substance ab use treatment and rclapse prevent ion. Although these experts suggested that soci al-skills traini ng ca n make a sig nificant co ntri bution to improving treatm ent strategies , they adm itted that little resea rc h had been done in th is ar ea until th e past fe w years. In a recent study, Hawkins and colleagues (1989) rand omly ass igned patients who were in the reen try phase of residen tial drug abuse treatment to ei ther a behavioralskills training course or a control group. The behavioral inter ve ntion e mp has ized dr ug refusal a nd avoidance skills , prob lem-solving, soc ial- and stress-related coping skill s (i.e., copi ng with depr ession, bei ng treated unfairly, a slip into dru g use, and oth er perso nal hig h-risk-for-relap se situations). Outcom e was assessed at 10 weeks, 6 months an d 12 months . Skills appeared to decay slig htly over time, but skill level was higher at 12 months in the behavioral group than in the control group . Nevertheless, skill s training did not affect dru g use during the follow-up peri od . Thi s fail ure to find an effect on dru g use could be at tributed to a decay in skills over time and low relapse rat es in both experime ntal and co ntrol groups. Th e application of the se soc ial-skills trai ning procedures needs to be investigated in the prevention of smoking relapse. Social Support. Gro up support and co ntinued therapist contact are forms of social support that hav e gen erally not bee n foun d to be effec tive in prev enting relapse (c.g ., Ham ilton & Born stein 1979). Su ch co ntinued contact may in fact be co unterproducti ve in cases where it fosters dependency and possibly undermines self-efficacy (Be st, Bass & Ow ens 1977). Li chtenstei n, Glasgow and Abrams (19 86) reviewed the results o f fi ve treatment outcome studies on soci al support and smoking cessation , each of which compared a basic behavioral program with the same program plu s a 228

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only recently begun to be reported in the smoking-cessation research literature. Brandon , Zelman and Baker (1987) compared the effects of a Pavlovian-exposure procedure with a coping skills-training program in facilitating the maintenance of long-term abstinence. Maintenance sessions were scheduled for 12 weeks after an initial smoking-cessation treatment. Both forms of maintenance intervention reduced relapse rates while these sessions were taking place, but not beyond this period. These researchers concluded that these maintenance procedures may exert only weak or transitory effects. Their findings also showed that subjects with a history of more psychological problems had poorer outcomes. They also speculated that such individuals may encounter more frequent and potent negative mood states that increase the risk of relapse. Alternatively, they may be less able to learn or use strategies to cope with negative affective states.

social support component added. None of these studies yielded significant between-group differences in smoking-cessation outcome. These negative fmdings could be attributed either to the irrelevance of social support to smoking-cessation outcome or the inadequacy of socialsupport training procedures in which spouses or co-workers were trained in methods for being more supportive. Correlational data indicated that perceived social support was related to successful smoking cessation and maintenance of abstinence. However, these researchers concluded that it may be difficult to change the behavior of significant others who are not supportive before training. In addition, individual differences need to be assessed to permit a better matching of intervention procedures with smokers' characteristics. Affect Regulation. The role of affect regulation in relapse prevention has recently been reviewed by Carmody (1989). In one study, Kamarck and Lichtenstein (1988) investigated the effects of program adherence and coping strategies on smoking-cessation outcome. Participants' use of intervention recommendations and other quitting strategies was assessed throughout treatment The results indicated that maintenance of abstinence was associated with greater adherence and coping. Specifically, shortterm maintenance (i.e., one to two months) was associated with a more extensive affect-regulation repertoire and use of stimulus control strategies during the initial smoking-cessation treatment. Long-term (one year) maintenance of abstinence was related to self-monitoring of smoking during the initial treatment. Kamarck and Lichtenstein speculated that affect-regulation strategies or stress-reducing skills may be more critical during the early stages of abstinence when ex-smokers are developing new behavioral repertoires for dealing with negative affect Self-monitoring. One particular self-regulation skill, self-monitoring, may facilitate the practice of other helpful behaviors learned during self-regulation treatment. In addition, self-monitoring may disrupt the chain of behaviors involved in the smoking routine. According to Kamarck and Lichtenstein (1988), this disruption may bolster the ex-smoker's confidence in his or her ability to control the smoking habit, facilitating a vigilant approach to quitting and timely coping in the face of temptations to smoke.

Pharmacological Approaches Physiological factors appear to play an important role in determining the course of abstinence versus relapse. Biological influences are involved in nicotine withdrawal, the reinforcing properties of nicotine, and the conditioned associations between specific cues and physiological responses (Pomerleau & Pomerleau 1984). Withdrawal symptoms may be less often associated with relapse episodes than negative mood-states (Shiffman 1986b, 1982); however, they still may represent powerful precipitating events, particularly during the early stages of maintenance. A growing recognition of these biological-addiction components of cigarette smoking has prompted the development of pharmacological treatments to facilitate smoking cessation. Nicotine Replacement Therapy. At least 13 controlled trials of nicotine chewing gum have been reported with over 5,400 smokers (see Carmody et al. 1988). The highest success rates have been found in smoking-cessation clinics where careful instructions were provided with adequate psychological support and follow -up. Lower success rates were obtained by general practitioners. Differences in success rates across studies have been attributed to differences in treatment methods used along with the nicotine chewing gum, differences in samples of smokers, and variations in their motivation to quit. Tonnesen and colleagues (1988) compared the effects of 2 mg and 4 mg nicotine chewing gum used in combination with group counseling. At 22-month followup, abstinence rates were 27% for the treatment groups compared with only 5.7% for an "advice-only" control group. The 4 mg nicotine gum was no more effective than the 2 mg gum . As other investigators have found, the best outcome occurred with low-dependent smokers.

Conditioning Approaches and Cue Exposure Cue Exposure. Cue exposure can serve to break conditioned links between smoking cues (e.g., presence of others smoking) and cravings. One approach involves a systematically graded cue-exposure procedure in which a hierarchy of smoking cues is constructed and the smoker is systematically exposed to these cues and encouraged to use coping strategies. Such cue-exposure methods have JOIU7laI of Psychoactive Drugs

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Pre ventin g Relaps e In Nicotine Addiction

Other forms of nicotine replacement therapy have also been investigated. For example, Hartman , Jarvik and Wilkins (1989) recently reported on the application of nicotine patches with three smokers. Reduction in cigareue smoking and urinary nicotine levels were observed in all three smokers. These researchers as well as other teams of investigators are now studying the effects of the nicotine patch with larger numbers of smokers in controlled trials. Nicotine replacement therapy may be more useful for facilitating short-term rather than long-term abstinence . The likelihood of relapse in the early stage of abstinence would be expected to be influenced by the degree of nicotine dependence because withdrawal symptoms may be more severe in more dependent smokers. This expec tation has served as one of the rationales for nicotine replacement therapy. Gro ss, Stitzer and Maldonado (1989) examined the effects of nicotin e chewing gum on postcessation weight gain . Their fmdings indicated that nicotine replacement therapy had a strong effect on reducing weight gain. Evidence for a dose-response relationship was also found . More nicotine gum use resulted in greater weightgain suppression. Subjects who used placebo gum reported greater po stcessation increases in eating and hunger. The results arc shown in Figure 4. Postcessation weight gain was suppressed by 50% in subjects who used active 2-mg nicotine gum . The 23-week follow -up data suggested that use of nicotine gum over a 1O-weekperiod delayed rather than prevented weight gain. These researchers concluded that use of nicotine gum during the first few months of follow-up may allow time to prepare people for dealing with or even preventing later weight gain by making changes in diet and exercise behaviors. The use of nicotine gum as a relapse prevention tool has not been directly tested , although the effects of nicotine gum have been examined in long-term follow-up studies. The potential use of nicotine chewing gum or other forms of nicotine replacement for long-term relapse prevention may depend on the degree to which conditioned nicotine-seeking and memory for nicotine use are involved in long-term relapse processes. To this end, additional basic research is needed on nicotine withdrawal. In addition, the dependent smoker needs to be characterized in terms of dose, smoking history, biochemical measures of addiction, motives for smoking, and delineation of withdrawal symptoms. The notion that the degree of nicotine dependence predicts outcome needs further documentation. Furthermore, the parameters for use and requirements for the optimal administration of nicotine chewing gum need to be clarified. Combined Behavioral-Pharmacological Approaches. Numerous outcome studies support the use of nicotine gum as a useful adjunct in smoking-cessation Journal ofPsychoactive Drugs

treatm ent. Interve ntions that com bine nicotine chewing gum with behavioral strategi es typically produce the best outcome results (Gold stein et a1. 1989; Carmody et al. 1988). Killen, Maccoby and Taylor (1984) studied the use of nicotine gum and self-regulatio n trainin g in smok ing relapse prevention . They compared the followi ng maintenance treatment condi tions: nicotine gum onl y, skills training only, and combined nicotine gum plus skills training. The nicotine gum was used for seven weeks. The combined format yielded an abstin ence rate of 50% at 10.5 months. Those ex-smokers in the gum -only condition may have been less prepared to cope effec tively with relapse-inducing episodes because they recei ved no skills training for this purpo se. Their abstinence rate was only 23%. However, the skills training alon e conditi on did not far e much better, with a fin al abs tinence rate of 30% . These researchers recomm ended further studies of the effect s of different gum- fading schedules on lon g-term maintenance. Lando, Kalb and McGovern (1988) developed and tested the effectiveness of behavioral self-help material s used in conjun ction with nicotine chewing gum . They concluded that such self-help materials needed to be improved by condensing and simplifying content and by using more attractive pictorial form ats. Goldstein and colleag ues (1989) recently com pared four nicot ine chewi ng gum int erventions for smok ing cessation: (I) behavioral treatm ent plus a fixed schedule of nicotine gum; (2) behavioral intervention plus an ad lib schedule; (3) education plus a fixed sched ule; and (4) education plus an ad lib schedule. Trea tment outcome results at six-month follo w-up indicated that subjects who partic ipated in either of the behavioral intervention s had a significantly greater abstinence rate (37%) than those who particip at ed in the educati on groups (18 %). T he nicotine chewing gum schedu le had no impa ct on treatment outcome. Interestingly, high-dependent smokers appeared to do better on the fixed sc hed ule, whereas low-dependent smokers were more successful on the ad lib schedule of nicotin e gum. However, these effects did not reach statistical significan ce. The inclusion of behavioral skills training appeared to enhance the effects of intervention. These investigators recommended that future studies arc needed to test the effects of a fixed schedule of nicotine chewing gum with heavy smokers. Clonidine . Nicotine c hewi ng gum represents the most promising pharm acological intervention to date. At the same time, other drug treatm ent aids are being developed. One of these is clonidine, which dampens central noradrenergic activity and thereby diminishes withdrawal symptom s (Sees & Clark 1988). However, cIonidin e also has powerful cardiovascular effects that must be weighed against its therapeutic effec ts. 230

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Figure4. Cumulative weight gain in pounds (M+SEM) for active gum (open circles) and placebo gum (closed circles) subjects over 10 postcessation weeks. Weight change is assessed in relation to baseline body weight, which was averaged over three preces sation measurements. Reprinted with permission from: Gross, 1.; Stitzer, M.L. & Maldonado, 1. 1989. Nicotine replacement Effects on posteessation weight gain . Journal ofConsulting and Clinical Psychology Vol. 57: 89.

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Preve nting Relapse In Nicotine Addiction

Although the transdcrmal clonidine patch has been used in only two clinical trials (Ornish, Zisook & McAdams 1988; Appel 1987), it appears to offer a practical solution to some of the limitations of oral clonidine and nicotine replacement therapy, particularly those related to patient noncompliance. The hesitance by some members of the medical community to use clonidine to assist smokers who wish to quit may reflect their reluc tance to play an aggressive role in the pharmacological treatm ent of nicotine withdrawal (Sees & Clark 1988). The advocates of clonidine in smoking-cessation treat ment argu e that cigarette smoking represents a serious enough public health problem to warrant exploration of such pharmacological methods by the medical community. Sees and Stalcup (1989) described a method for combining clonidine and nicotine replacement in the treatment of nicotine withdrawal symptoms. They emphasized that the treating physician can control the rate of nicotine withdrawal by tapering the amount of nicotin e chewing gum and also control the extent to which nicotine withdraw al symptoms are treated by using transdermal clonidine. If it is true, as many exp erts have proposed , that a majority of smokers who successfully quit are less dependent on nicotine than those who are unsuccessful, then there may be an increasing proportion of smokers who are physically addicted to nicotine and who may require medicinal interventions , such as transdermal clonidine, to decrease physiologically bas ed nicotine withdrawal symptoms when attempting to quit (Sees & Clark 1988). Othe r Pharmacological Agents. Antianxiety and antidepressant agents have also been investigated in the treatment of nicotine addiction. For example, Gawin, Compton and Byck (1989) recently tested the effects of buspiron e, a nonsedative antianxiety drug, in the treatment of nicotin e addiction in an open, uncontrolled sixweek trial. Buspirone appeared to reduce cravings, withdrawal anxiety, and fatigue. These are withdrawalrelated symptoms that have typically not been affected by nicotine chewing gum. Similarly, in a double-blind study, Edwards and colleagues (1989) examined the effects of doxepin, an antidep ressant ag ent, as an adjunct to smoking-cessation treatment. Their results were promi sing, but preliminary. The potential role of such pharmacological agents in the treatment of nicotine dependence appears worthy of further exp loration.

behavioral smoking-cessa tion treatment programs are unable to quit or remain abstinent It appears that more aggressive approaches for comb ating physiological aspec ts or pharmacological -conditioning proc esses involved in nicotine addiction need to be considered. In addition, the larger social and cultural contexts tend to support smoking in several ways. As societal norms con tinue to change and commun itywide approaches take effect, greater treatment gains will be realized. In future studies of relapse prevention methods, there will need to be a greate r emph asis placed on intervention avenu es that are likely to have the greatest publi c health impact , incl udi ng pr imary care se tti ngs, mass med ia , worksites, and the application of these intervent ion procedures with neglected populations (e.g., ethnic minorities, women, heavy smokers, other substance abusers, and the mentally ill). Worksite smoking-cessa tion programs are becomi ng more commonplace, and are now even includ ing such inno vative intervention s as computerized nico tine fading (e.g., Burling et aI. 1989). Greater effort needs to be direct ed at de veloping more sophisticated maintenan ce strateg ies and re lapse prev en tion techniques in such worksite programs. Further research is also needed to develop the optimal format for the delivery of relapse prevention therapy not onl y at worksi tes but also for home use and application in various clinical settings. Ginne (1989) recently described a model of tertiarylevel intervention s for hard-core smokers who have a history of smoking-cessation failures, addic tive disorders, smoking-related diseases, and/or psychiatric impairment. This intensive intervention incl udes a relap se prevention strategy, which uses Marlatt' s model. The effects of such intervention models need to be investigated with these populations of hard-core smokers. Relapse prevent ion procedu res also need to be tested with wome n smo kers, hig h-ri sk medical patients, and blue-collar workers beca use the prevalence of smoking L

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