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Section 6
Rules of Relapse in Tobacco Dependence

Question 6 | Answer Booklet | Table of Contents

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In the last section, we will discussed smoking triggers.  The four smoking triggers we examined were places, people, time, and feelings.   

In this section, we will discuss relapse.  Because relapse is highly individualized, we will discuss two situations that cause relapse as well as the three rules of relapse.  The two situations that cause relapse are emotional upset and boredom.  The three rules of relapse are practical rules of avoidance that have been had a high rate of productivity in preventing relapse in clients who closely follow them.   You might consider playing this section during your next session with a tobacco dependent client. 

Overcoming Two Situations That Cause Relapse

♦ #1 - Emotional Upset
First, let’s discuss situations that cause relapse.  I have found that two major situations tend to cause relapse in my tobacco dependent clients.  The two major situations are emotional upset and boredom.  Now, let’s discuss how emotional upset can lead to relapse.  As you know, the situations in which relapse usually occurs are framed by the client’s emotions and state of mind. 

Therefore, the first predictable situation that may cause a relapse is emotional upsets.  Do you find that clients who relapse due to emotional upsets may experience short term relief, but later feel much worse due to feelings of guilt, remorse, or failure?  The dialogue I had in a session with Emma, age 33, helps illustrate the point that relapse brings about only short term relief.  Emma stated, "Things were terrible at work.  I borrowed some cigarettes from a coworker, and then later I bought a pack."  I asked Emma how having a cigarette mad her feel.  Emma stated, "At the time, great.  But not as great as I thought it would make me feel.  Then, later, I just felt awful!"

Emma and I discussed ways she could avoid future relapses due to emotional upset.  For example, Emma decided to use positive self talk such as telling herself that though she is unable to control what is upsetting her, she is able to control whether or not she smokes.  Emma added that smoking doesn’t really make upsetting situations any better.  She stated, "When you’re already upset, losing even more control to cigarettes just makes you feel that much worse."  At a later session Emma stated, "Things got really bad at work again.  More than thirty people got laid off.  I was spared, but I’m still freaked out.  I may not be so lucky next time.  But one of the things that keeps me going is that I’m not smoking.  I’m really proud of myself."

Another client mentioned that the idea of repeating smoking cessation is enough to deter future relapse due to emotional upset.  Greg, age 29, stated, "I was so close to relapsing.  In fact, I was on my way to buy a pack.  Then I started thinking about how hard it was to quit in the first place.  I spent a lot of time and effort on quitting.  I realized I didn’t want to go through all that work again!"

♦ #2 - Boredom
Boredom can also lead tobacco dependent clients to relapse.  Dull, repetitive jobs where smoking is not prohibited, long telephone conversations or extended driving times may bore a client and lead to relapse.  Have you also found that relapses from boredom may occur in clients who live alone?  As Jacob told me, "When my friends aren’t around and I’m alone, there’s nothing to do.  At least smoking is something to do." 

I stated to Jacob, "There are many things you can do instead of killing yourself!  The key is alternatives.  Give yourself a variety of things to do that will keep your hands or your mouth busy.  Reading a book, doing a crossword, or having a light snack might help you keep busy."  As you know, some tobacco dependent clients gain weight after quitting smoking.  Therefore, if food becomes an alternative to boredom, you might consider reviewing healthy eating habits with your client. 

♦ The Three Rules of Relapse
In addition to the two situations that cause relapse, we will examine three rules of relapse.  Dr. Klesges runs a smoking cessation clinic in Memphis and reports that of all his clients, not one who has closely followed these three rules of relapse has permanently gone back to smoking.  Dr. Klesges may have had unusual rates of success using these rules, but other statistics help prove the value of the three rules of relapse.  For example, each of the clients I have treated who went back to smoking broke at least one of these rules.  As you listen to the three rules of relapse, consider how following the rules can help your client avoid relapse. 

The three rules of relapse are:
1.  Never smoke a cigarette that is given to you. By never smoking a cigarette that is given to them, clients eliminate the spontaneity that tends to characterize relapse.
2.  Never buy cigarettes in the place where you are about to relapse.  This rule reinforces the first rule, and gives the client time to consider whether or not they really want to smoke.  A productive addition to this rule is to ask your client to travel at least ten minutes out of their way to buy cigarettes.  By driving or walking for ten minutes, clients tend to realize how pointless relapse would be.
3.  After buying a pack of cigarettes and smoking one, throw the rest of the pack away.  Some tobacco dependent clients may consider this rule a little extreme.  However, clients tend to understand that cigarettes kill, and are better off in the garbage.  Also, you can tell your clients, if you want another cigarette, fine.  Buy another pack, smoke one, and throw that pack away, too. 

Consider your tobacco dependent client.  How could these rules help your client avoid relapse?  Could your client benefit from carrying a card with the three rules of relapse printed on them?

In this section, we have discussed relapse.  Because relapse is highly individualized, we discussed two situations that cause relapse as well as the three rules of relapse.  Two situations that cause relapse are emotional upset and boredom.  Do you have a tobacco dependent client that would benefit from listening to this section during your next session?
Reviewed 2023

Peer-Reviewed Journal Article References:
Kirchner, T. R., Shiffman, S., & Wileyto, E. P. (2012). Relapse dynamics during smoking cessation: Recurrent abstinence violation effects and lapse-relapse progression. Journal of Abnormal Psychology, 121(1), 187–197. 

Nakajima, M., & al'Absi, M. (2012). Predictors of risk for smoking relapse in men and women: A prospective examination. Psychology of Addictive Behaviors, 26(3), 633–637.

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.

Robinson, J. D., Li, L., Chen, M., Lerman, C., Tyndale, R. F., Schnoll, R. A., Hawk, L. W., Jr., George, T. P., Benowitz, N. L., & Cinciripini, P. M. (2019). Evaluating the temporal relationships between withdrawal symptoms and smoking relapse. Psychology of Addictive Behaviors, 33(2), 105–116. 

Strong, D. R., Leventhal, A. M., Evatt, D. P., Haber, S., Greenberg, B. D., Abrams, D., & Niaura, R. (2011). Positive reactions to tobacco predict relapse after cessation. Journal of Abnormal Psychology, 120(4), 999–1005.

QUESTION 6
What are the three rules of relapse? To select and enter your answer go to Answer Booklet.

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