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Section 12
A Stage Model for Behavioral Interventions
with Tobacco-Dependent Clients

Question 12 | Test | Table of Contents

Motivational Interviewing: Precontemplation Stage
To select the most appropriate interventions, the therapist needs to know the client's present readiness to change. Offering a prescription for nicotine replacement to a client who is in the precontemplation stage is unlikely to be successful, because doing so essentially asks the client to move from precontemplation to action without going through the necessary intervening stages. Rather, the therapist should encourage the client in the precontemplation stage to think about his or her smoking and to consider the possibility that smoking is a problem that needs attention. Brief interventions can be effective in the precontemplation stage and as the client moves from one stage to the next. Effective interventions include the following:
Educate the client about the effects of smoking.
Recommend changes in behavior.
List options for achieving behavioral change.
Discuss the client's reactions to the therapist’s feedback and recommendations.
Follow up to monitor and reinforce behavioral change.

This process, known as "motivational interviewing," uses empathy rather than confrontation. It acknowledges that the client, not the therapist, is responsible for changing behavior.

Contemplation Stage
If further discussion on the return visit reveals that the client now agrees that smoking is a problem and would like to consider quitting, the client has entered the contemplation stage. Interventions to consider at this stage include providing further education about the effects of smoking and encouraging the client to consider the positive aspects of not smoking, such as improved health, a more positive self image, and economic savings.

Preparation Stage
Once the client agrees that the benefits of not smoking outweigh the pleasure derived from smoking and has decided to quit, he or she has entered the preparation stage. At this point, it is appropriate to discuss various nicotine replacement systems, the possible use of bupropion, and the need for social and family support. The therapist should also help the client develop a clear plan for smoking cessation. Tasks for the client and therapist during the preparation stage may include the following:
Setting a definite quit date. Often, a meaningful date, such as a birthday or anniversary, provides the client with increased motivation.
Gathering support for smoking cessation. The client should let family members and other significant persons know that he or she has decided to quit smoking on a certain date, and should ask those individuals for help. The therapist might encourage the client to take part in a support group or a community or agency program that focuses on smoking cessation.
Preparing the environment. The client should be counseled to remove cigarettes, ashtrays, and other smoking-related paraphernalia from his or her home, car, and office. The client should ask others not to smoke in his or her presence.
Formulating plans to avoid triggers. When prompted, many clients can identify images, rituals, sensory experiences, and emotional rewards that they associate with smoking. The therapist and client can begin to discuss healthy substitution behaviors that might help prevent relapse. Counseling clients to avoid alcohol is a good strategy because drinking lowers inhibitions, thereby reducing the chance of successful smoking cessation.
Selecting a nicotine replacement system, if needed.

Action And Maintenance Stages
The action stage begins on the quit date. By this date, bupropion should have been started (if used), the nicotine replacement system of choice should be on hand (if used), and the client's environment should have been cleared of smoking-related materials.

During the action stage, behavioral support through self-help or professionally run group meetings, frequent office visits, and/or telephone calls from support personnel can enhance the effectiveness of the cessation attempt. The purpose of these contacts should be to support continued smoking cessation in the recently abstinent smoker. These contacts should be made at least weekly in the first month, and again when the clients stops nicotine replacement and bupropion therapy.
It is important for the client to report perceived benefits from having stopped smoking, side effects of medications, and current or anticipated difficulty in maintaining abstinence. Healthy substitution behaviors may help to prevent relapse.

Dealing with Relapse
Most clients relapse within the first six to 12 months of a smoking cessation attempt. If a client relapses, the therapist needs to encourage the client to try again. It is useful to review the treatment plan to determine what did and did not work.
A client may not return immediately after a relapse and may smoke for months before another visit. At that point, the client's readiness to change needs to be reevaluated, and the smoking cessation process must be repeated. Nicotine dependence is a tenacious and difficult addiction to treat successfully. Clearly, perseverance on the part of the client and the therapist is most effective for achieving permanent abstinence. The use of nicotine replacement and bupropion can improve results, and the application of readiness-to-change strategies and motivational interviewing techniques are essential for success. Behavioral therapy and support in a group setting have been shown to improve quit rates. Individual counseling can also be effective. A supportive telephone call during the first few days of abstinence may help the client who is trying to quit smoking.
- Mallin, Robert; Smoking Cessation: Integration of Behavioral and Drug Therapies; American Family Physician; March 2002; Vol. 65 Issue 6

Personal Reflection Exercise #5
The preceding section contained information about  a stage model for behavioral interventions with tobacco dependent clients.  Write Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Correlations Between the DMN and the Smoking Cessation
Outcome of a Real-Time fMRI Neurofeedback Supported
Exploratory Therapy Approach: Descriptive Statistics
on Tobacco-Dependent Patients

- Paolini, M., Keeser, D., Rauchmann, B. S., Gschwendtner, S., Jeanty, H., Reckenfelderbäumer, A., Yaseen, O., Reidler, P., Rabenstein, A., Engelbregt, H. J., Maywald, M., Blautzik, J., Ertl-Wagner, B., Pogarell, O., Rüther, T., & Karch, S. (2022). Correlations Between the DMN and the Smoking Cessation Outcome of a Real-Time fMRI Neurofeedback Supported Exploratory Therapy Approach: Descriptive Statistics on Tobacco-Dependent Patients. Clinical EEG and neuroscience, 53(4), 287–296. https://doi.org/10.1177/15500594211062703


Peer-Reviewed Journal Article References:
Kurti, A. N. (2020). Reducing tobacco use among women of childbearing age: Contributions of tobacco regulatory science and tobacco control. Experimental and Clinical Psychopharmacology, 28(5), 501–516.

Palmer, A. M., & Brandon, T. H. (2018). How do electronic cigarettes affect cravings to smoke or vape? Parsing the influences of nicotine and expectancies using the balanced-placebo design. Journal of Consulting and Clinical Psychology, 86(5), 486–491.

Pedersen, E. R., Tucker, J. S., Davis, J. P., Dunbar, M. S., Seelam, R., Rodriguez, A., & D'Amico, E. J. (2020). Tobacco/nicotine and marijuana co-use motives in young adults: Associations with substance use behaviors one year later. Psychology of Addictive Behaviors. Advance online publication.

QUESTION 12
 What are five tasks for the client and therapist during the preparation stage of smoking cessation? To select and enter your answer go to Test.

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