1. Rocky Mountain Tobacco Treatment Specialist Certification (RMTTS-C) Program

2. Module 8: Relapse Prevention
Training Notes:
In this module, we will discuss relapse prevention.

3. Module 8: Relapse Prevention Objectives
Learn about relapse prevention and related concepts
Discuss strategies and skills to reduce relapse
Identify appropriate referrals to reduce relapse
Review treatment strategies for someone who has relapsed
Training Notes:
This module provides information on:
Relapse prevention and related concepts
Strategies to reduce relapse
Ways to make referrals to reduce relapse
Treatment strategies for relapse

4. Tobacco Dependence = Chronic Disease State
Often requires repeated intervention and multiple attempts to quit
Most smokers want to quit and have made serious quit attempts
70% of current smokers have expressed a desire to quit
Effective treatments exist and increase rates of long-term abstinence
Training Notes:
Tobacco dependence is a chronic disease state. The chronic disease model recognizes the long-term nature of tobacco dependence, with an expectation that patients may have periods of relapse and remission. The chronic disease model emphasizes the importance of continued patient education, counseling and advice over time (Fiore et al., 2008).
Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence (Fiore et al., 2008).
Most smokers want to quit. In fact, more than 70% of smokers report wanting to quit and 44% report trying to quit every year. It’s important to note that most of these attempts are unaided and unsuccessful (Moran, 2013).
Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders (Fiore et al., 2008).

5. Tobacco Use Terminology
Abstinence – no use of tobacco at all
Lapse – isolated or single use of tobacco
Relapse – return to regular use of tobacco after a period of abstinence
Training Notes:
There is various terminology used in the context of addiction/tobacco dependence (Moran, 2013).
Most relapse occurs within the first three months of quitting. During this time, individuals should be closely monitored, all successes should be reinforced and they should be offered relapse prevention interventions (Kenford & Fiore, 2014).
Being prepared is the best strategy to prevent relapse (Kenford & Fiore, 2004).
Relapse Prevention:
Intervention strategies intended to prevent a return to regular tobacco use

6. Relapse Prevention Relapse is common but not inevitable
Relapse prevention begins at the beginning of treatment, not just after a relapse occurs
Preventing relapse often involves behavioral, cognitive and pharmacological components
Training Notes:
According to a recent epidemiological study, the risk for relapse during the first 12 months is over 50% (García-Rodríguez et al., 2013).
Relapse prevention begins at the beginning – at the initial assessment, not just after a relapse occurs (Moran, 2013).
Initial and follow-up counseling should focus on learning to anticipate and cope with the challenges that often lead to relapse (Moran, 2013). Counseling should include a variety of components like pharmacotherapy, behavioral interventions and cognitive behavioral treatment.
The risk of relapse during the first 12 months after stopping tobacco use is over 50%

7. Relapse Prevention Strategies
Avoid any tobacco use, particularly in the first two weeks of a quit attempt
Identify high-risk situations
Prepare and plan for ways to deal with high-risk situations when they occur
Enhance self-efficacy through supportive relationships and behaviors that support well-being
Training Notes:
Any smoking at all, particularly in the first two weeks of a quit attempt, significantly increases relapse rates. Additionally, most relapse occurs within the first three months of abstinence (Kenford & Fiore, 2004). Among individuals who had been abstinent for over a year, risk of relapse decreased hyperbolically as a function of time, and stabilized around 10% after 30 years of abstinence. (García-Rodríguez et al., 2013).
People preparing to stop their tobacco use should remove tobacco and tobacco-related products from their environment (Kenford & Fiore, 2004). Identifying high-risk situations that may trigger a relapse helps the individual to prepare and plan for how they will handle the situation when it arises. Individuals may also make changes in their environment to avoid being triggered.
As people engage in tobacco-free behaviors or other behaviors that facilitate their well-being, their experience can serve to increase their confidence that they can live a tobacco-free life (Morris, Morris, Martin & Lasky, 2013).

8. Identify High-Risk Situations & Triggers
Specific behaviors, emotions, environments or people can act as triggers for tobacco use:
Negative emotional state
Interpersonal conflict
Social pressure
Positive emotional state
Lifestyle factors
Urges and cravings
Training Notes:
It is important that individuals are aware of what situations or triggers will make it difficult for them to remain abstinent. By visualizing these situations, they can be prepare a plan to overcome their craving to use tobacco. A few common situations or triggers include (Moran, 2013):
Negative emotional state (i.e., anxiety, anger, depression)
Interpersonal conflict situation (i.e., conflict or stress within relationships)
Social pressure (i.e., influences by a person or group of people)
Positive emotional state (i.e., happiness or joy that leads to “celebrating”)
Lifestyle factors (i.e., attitude, habits, socioeconomic status, etc.)
Urges (i.e., a strong desire or impulse or cravings)
Negative emotional state is associated with the highest rate of relapse. Negative emotional state and interpersonal conflict led to half of relapse incidents according to analysis (Kenford & Fiore, 2004).

9. Saying No – Situations & Strategies
Training Notes:
This is an example activity from the BHWP DIMESIONS: Tobacco Free Group curriculum. Whether this activity is completed in a group setting or on an individual basis, it is helpful to discuss the different situations that may be triggers to tobacco use. This discussion can assist an individual with developing a plan of action to manage different situations and use alternative behaviors. Encourage people to examine ways to get around barriers to successful implementation of their plan. It is important for people to remember that these are new behaviors to them that require attention, focus and practice. You may want to role play with individuals about how to say “No” to tobacco when offered.

10. Conversations to Support Relapse Prevention
What do you like about living tobacco-free?
How would you like to address the challenges around living tobacco-free?
What are some successes you experienced this week?
What makes it hard to live tobacco-free?
What changes do you notice in your physical health?
How has stopping your tobacco use helped you?
Training Notes:
Conversations that support relapse prevention should be balanced in their focus, exploring successes as well as challenges. Congratulate every individual for the steps they have taken towards living tobacco-free, no matter how small. Empower individuals to discover ways to address the challenges they experience around living tobacco-free. Stay present and engaged with the individual around their cessation efforts (Morris, Morris, Martin, & Lasky, 2013).
How have your relationships changed since you stopped using tobacco?

11. Intensive Support for Relapse Prevention
Challenge
Suggested Intervention
Lack of support
Schedule follow-up visits or telephone calls
Help identify other sources of support
Provide or refer the person to tobacco cessation counseling or support
Negative mood or feelings of depression
If significant, provide counseling or refer the individual to a specialist
Encourage the person to engage in behavioral interventions for smoking cessation
Training Notes:
If a person is struggling with living tobacco-free, explore their challenges to determine whether a referral to more intensive treatment or adjustments to the treatment plan are needed.
When someone is learning to live tobacco-free, it is important that they have the support they need. If a person feels unsupported, you may need to help them identify other sources of support.
Negative mood or feelings of depression can arise when quitting tobacco. Encourage individuals to engage in behavioral treatments to help them address these feelings. If these feelings persist, provide counseling or referrals to other specialists, as needed.
Reference for this slide: Morris, Morris, Martin, & Lasky, 2013.

12. Intensive Support for Relapse Prevention
Challenge
Suggested Intervention
Strong or prolonged withdrawal symptoms
Extend, add or combine the use of FDA-approved tobacco cessation medications
Encourage the individual to engage in behavioral interventions
Reduced motivation or feeling deprived
Reassure the person that these feelings are common
Recommend rewarding activities
Encourage the individual to engage in behavioral interventions
Emphasize that periodic tobacco use will increase urges and make quitting difficult
Training Notes:
If someone is feeling strong or prolonged withdrawal symptoms, it may be appropriate to extend, add or combine FDA-approved tobacco cessation medications.
People often experience decreased motivation to quit, especially after multiple relapse. Reassure them that this is a common experience they can overcome. Recommend they engage in rewarding, healthy activities to decrease feelings of deprivation. And make it clear that periodic or limited use of tobacco will make quitting more difficult.
Reference for this slide: Morris, Morris, Martin, & Lasky, 2013.

13. Intensive Support for Relapse Prevention
Challenge
Suggested Intervention
Weight gain
Recommend increasing physical activity and discourage strict dieting
Reassure the individual that weight gain after quitting is common
Emphasize the importance of a healthy diet
Maintain the client on pharmacotherapy known to delay weight gain
Refer the person to a specialist or program
Help connect the individual to additional support, as needed
Training Notes:
Weight gain during tobacco cessation is common. It is important to emphasize that this should not discourage people from quitting. There are many ways to mediate weight gain, either through increasing daily physical activity, maintaining a healthy diet or meeting with a specialist.
Bupropion SR and some nicotine replacement therapies, particularly the nicotine gum, are known to delay weight gain. Recommend these medications if a client’s weight gain is a concern.
Reference for this slide: Morris, Morris, Martin, & Lasky, 2013.

14. Post-Relapse Conversations
What have you learned from this relapse (or lapse) ?
How did you decide to start using tobacco again?
What was going on for you just before your relapse (or lapse)?
What will you do differently next time?
What did you learn from this experience?
What helped you to stop using tobacco?
Training Notes:
The conversation with someone who has already relapsed will look different from the relapse prevention conversation. It is important to identify what led to the relapse. In particular, it is useful to address how the person made the decision to use tobacco. It is also important to identify ways to prevent future relapse by creating an action plan that outlines steps to take the next time a similar situation occurs (Capenneto, Keller, Bruno, & Polosa, 2013).
What do you need (going forward) to support a tobacco-free life?

15. Additional Support and Referrals
Quitline: Quit-Now
Telephone counseling
Referrals for additional support
May provide NRT or other medications
May be available in multiple languages
Nicotine Anonymous
In person, telephone and online meetings
Printed materials
Training Notes:
There are many additional supports that individuals can access.
Quitlines are a key component to state tobacco control programs in the U.S.
They have been proven effective at helping people stop their tobacco use.
Quitline services may be provided free-of-charge. They provide telephonic counseling, self-help materials and referrals for additional support.
Some quitlines may provide nicotine replacement therapy or other cessation medications. This differs by state.
Some quitline services may be available in other languages as well.
Nicotine Anonymous provides in person, telephone and online meetings. On their website ( they provide information about their meetings as well as online materials and resources.

16. Pre-Cessation Discussion
Relapse Prevention
Pre-Cessation Discussion
Training Notes:
Discuss the vignette described on the next slide as a large group.

17. Pre-Cessation Discussion
Evelyn is a 58-year-old African American woman who says she is ready to quit smoking. She smokes just under a pack a day. Evelyn’s daughter has been “badgering” her to quit. Evelyn indicates that she wants to be alive and healthy to spend time playing with her three grandchildren. Her husband, who also smokes, supports her decision to quit but continues to smoke inside the house. The hospital where she works as a nurse is tobacco-free, but she has a co-worker who takes smoke breaks with her. Evelyn is worried that she will gain weight since she has worked hard over the last year to lose 14 pounds.
Training Notes:
In this scenario, Evelyn has not quit yet, but she is considering it.
As a large group, consider these questions:
What specific concerns do you have about triggers for relapse?
What information would you share with her about relapse prevention? Why?
What supports and resources would you want to have in place to prevent relapse?

18. Post-Cessation Role Play
Relapse Prevention
Post-Cessation Role Play
Training Notes:
Partner with another trainee. One person will be the counselor and the other the client. Perform a role play based on the vignette described on the next slide.

19. Post-Cessation Role Play
Evelyn has been tobacco-free for the last three weeks. She is taking bupropion and using nicotine gum (about 6 pieces per day). Her husband has agreed to smoke outside and is considering quitting. Her daughter is very happy that Evelyn has stopped smoking. Although Evelyn has more energy and continues to be active, she has gained 5 pounds, which is concerning to her. She had a cigarette when she went out for a drink with her co-worker after a particularly stressful day at work. She is upset and feels like she failed. She wonders if she will ever be “free” from tobacco.
Training Notes:
Partner with another trainee. One partner will be the counselor and the other the client. In this scenario, Evelyn has been quit for three weeks but has experienced a lapse. She is meeting with a TTS for a follow up appointment.
Evelyn has been tobacco-free for the last three weeks. She is taking bupropion and using nicotine gum (about 6 pieces per day). Her husband has agreed to smoke outside and is considering quitting. Her daughter is very happy that Evelyn has stopped smoking. Although Evelyn has more energy and continues to be active, she has gained 5 pounds, which is concerning to her. She had a cigarette when she went out for a drink with her co-worker after a particularly stressful day at work. She is upset and feels like she failed. She wonders if she will ever be “free” from tobacco.
Perform a role play based on the above vignette. Role play a discussion with Evelyn about her lapse from a motivational interviewing perspective. Address any concerns she has and strategize ways to prevent future lapses.

20. http://www.bhwellness.org/resources/toolkits/ Training Notes:
The DIMENSIONS: Tobacco Free Toolkit for Healthcare Providers offers strategies for helping people stop tobacco use and maintain a tobacco-free life. Look to “Maintenance” section for more information about relapse prevention.

21. Relapse Prevention Discussion Training Notes:
Allow 5-10 minutes for discussion.