Smoking goes through phases in a progressive way, and it is very important to know in which phase the patient is.
- 35% of smokers are in the Precontemplation Phase, that is, they do not even think about the need to quit;
- 50% are in the Contemplation Phase, they wish to quit smoking within a period of no more than 6 months;
- 15% of smokers are in the Preparation Phase, i.e. they want to quit smoking and want to make a serious attempt in less than 1 month;
- the Action Phase is when they are quitting smoking.
Until the patient is in the Preparation Phase, we should not start smoking cessation treatment, since there is a high probability of failure. We can only motivate them to advance to the next phase.
It is necessary for the patient in the Preparation Phase to move on to Action and, for this, it is necessary to make a correct diagnosis of smoking, which adapts the treatment to the individual characteristics of each smoker. This will be done on the basis of the patient’s history, which includes minimum data such as the age at which he/she started smoking, mode of smoking and time in years that he/she has been smoking, as well as previous quit attempts, treatments used in them and analysis of the reason for relapse.
Treatment for smoking cessation
The smoking patient will be asked to fill in a 7-day calendar sheet, where he/she will write down the number of cigarettes smoked each day, marking the morning, afternoon and evening. In this way we will know (he and we) when he smokes more or less. In addition, another sheet of 1 day only, for him to write down where he was, with whom, what he felt before and after each cigarette.
We analyze the reasons that have led him to make the real decision to quit smoking, and we quantify the degree of motivation he has at that moment. If we detect that he is not sufficiently motivated, according to the tests, we should invite him to postpone the start of treatment.
In our experience, the reasons that most lead these patients to ask for help are:
- Parents with young or preadolescent children. The main motivation is to please their children, “my children do not want me to smoke”, as if it were a gift for them. When they have older children and they too are smokers, the strong motivation is to be a role model for their children to quit.
- Young women are more difficult to motivate because of the fear of gaining weight. Another negative factor in them is the constipation that occurs when nicotine is withdrawn. We should not forget that this problem is very frequent in them. On the other hand, when they are pregnant is probably the best reason to quit smoking, as well as their husbands, either to support their wives or to create a healthier environment for their baby.
- Women in pre-menopausal, menopausal, or in the recent post menopause, have many insomnia problems. Both the withdrawal syndrome, when they are in the withdrawal phase, and the pharmacological treatment used, make insomnia much worse. Hence, it is more difficult for women to quit smoking; for them, the ideal time is during pregnancy or during their children’s infancy.
- In older or middle-aged people, in those who already have heart, vascular or lung problems, the main reason is to improve or prevent their disease from progressing.
- We are seeing more and more young people who come for social reasons: to get a good job, to be frowned upon in some social groups, or because all their friends are quitting.
Analyze the degree of physical dependence, caused by the amount of nicotine in the blood, and other types of dependence that are generated: psychological, social and behavioral dependence. Women tend to have more social and behavioral dependence and men have more physical and psychological dependence.
Smokers maintain their habit through behavioral reinforcement: positive reinforcement: “I feel very good, it makes me feel like a leader, it makes me feel safe”… or negative reinforcement: “I am afraid of not getting over it, of having a bad time, of failing again, of getting fat”….
The treatment of smoking is twofold:
- Medication, which treats the physical dependence caused by Nicotine. In order to choose it, relevant factors for the specific patient must be taken into account: they do not want to gain weight or have strong problems of constipation or insomnia (in the case of women). The presence of depression or some other psychiatric problem may modify the choice of treatment.
- Cognitive-behavioral therapy, which treats the other types of dependence. It is practically the same for all patients, although the motivating reasons may be different in each of them and we must know them in order to place more emphasis on them. For this reason, and in order to be able to individualize each case as much as possible, a good diagnosis of everything related to smoking history is essential. In this type of therapy, experience and involvement with the patient is of great help to achieve success.
The smoker in the Action Phase (quitting smoking) is very vulnerable, feels insecure and needs to feel supported or have an easy grip in moments of craving (irresistible desire to smoke). A good doctor-patient relationship, explaining in their language what they are going to feel as the days of abstinence progress or anticipating the bad ones will prevent them from feeling afraid when they appear, thus strengthening their trust in the therapist, a key factor for success.
When the smoker has a strong social component and almost all of his friends smoke, he is instructed to avoid seeing them at least for the first 40 days. If they have a strong association between smoking and travel, they are instructed to avoid traveling or to travel with a non-smoker who can help them.
Drug treatment is also necessary, as it treats physical abstinence. This starts within a day or 2 days of not smoking at all and increases to a maximum, usually within 40 days. From then on, it decreases until it disappears in about 3 months, time that usually lasts the treatment except for complications or relapses. In that case, we can extend up to 6 months or even low doses of the drug for 1 year.
There are first or second line drugs, depending on the percentage of success with each one of them. But since not all patients can be put on the most successful drugs, it is fortunate to have more variety.
Relapses are avoided fundamentally with behavioral therapy, motivating the patient on the points that were most important to him, for example, those that led him to ask for help.
At the end of the treatment, I invite them to fill out a sheet of paper with the benefits they feel after quitting smoking and this sheet of paper should be kept very close at hand, for moments of weakness or possible relapses.
A patient is already an ex-smoker one year after quitting smoking.