ADDICTION AND CHANGE: Understanding and Intervening in Prevention and Cessation of Smoking

1
ADDICTION AND CHANGEUnderstanding and
Intervening in Prevention and Cessation of Smoking

• Carlo C. DiClemente, Ph.D. ABPP
• Director MDQUIT Resource Center
• www.mdquit.org
• UMBC Psychology
• www.umbc.edu/psych/habits

2
What are Addictions?

• Habitual patterns of intentional, appetitive
  behaviors
• Become excessive and produce serious consequences
• Stability of these problematic behavior patterns
  over time
• Interrelated physiological and psychological
  components
• Addicted individuals have difficulty modifying
  and stopping them

3
Etiology of Addictions
A BIO PSYCH SOCIAL SPIRITUAL PERSPECTIVE
Conditioning
Environment
Social Influences
Abuse
Personality
Initial Use
Self-Regulated Use
Physiology
Coping/Expectancies Spiritual Values
Genetics
Dependence
Reinforcement
All of these factors can have arrows to initial
experience and then to any or all of the three
patterns of use. Most could have arrows that
demonstrate linear or reciprocal causality as
well
4
BECOMING ADDICTED

• Happens over a Period of Time
• Has a Variable Course
• Involves a Variety of Predictors that can be both
  Risk and Protective Factors
• Involves a Process of Change

5
SUCCESSFUL RECOVERY FROM ADDICTIONS

• Occurs over long periods of time
• Often involves multiple attempts and multiple
  treatments
• Consists of self change and/or treatment
• Involves changes in other areas of psychosocial
  functioning

6
Change the Integrating Principle

• No single developmental model or singular
  historical path can explain acquisition of and
  recovery from addictions
• Understanding the Process of Change and how
  individuals change provides a developmental, task
  oriented, learning based view that can be useful
  to clinicians and researchers using a variety of
  traditional etiological and cessation models

7
Addiction and Change

• Both acquisition of and recovery from an
  addiction require a personal journey through an
  intentional change process
• The journey is influenced by personal decisional
  considerations and choices
• Personal choices are influenced by and, in turn,
  influence genetic, developmental,
  characterological, and social forces
• There is an interaction between the individual
  and the surrounding risk and protective factors
  that involves a Process of Change

8
How Do People Change?

• People change voluntarily only when
• They become interested and concerned about the
  need for change
• They become convinced the change is in their best
  interest or will benefit them more than cost them
• They organize a plan of action that they are
  committed to implementing
• They take the actions necessary to make the
  change and sustain the change

9
Stage of Change Tasks

• Precontemplation
• Not interested
• Contemplation
• Considering
• Preparation
• Preparing
• Action
• Initial change
• Maintenance
• Sustained change

• Interested and Concerned
• Risk-Reward Analysis Decision making
• Commitment Creating an Effective/Acceptable
  Plan
• Implementation of Plan and Revising as Needed
• Consolidating Change into Lifestyle

10
(No Transcript)
11
THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Sustained Cessation
Dependence
RECOVERY
12
Theoretical and practical considerations related
to Prevention and Stages of INITIATION
Expectancies/Beliefs Decision-Making
Self-efficacy
Precontemplation Contemplation
Preparation Action Maintenance
Personal Environmental Decisional
Cognitive/ Behavioral Concerns Pressure
Balance Experiential
Processes (Pros Cons)
Processes


Experimentation Casual use Regular Use
Dependence
13
Distribution of Stages of Smoking Initiation by
Wave School Status
14
A STAGE BY ADDICTIVE BEHAVIOR PERSPECTIVE
ON ALLEN
TYPE OF BEHAVIOR
STAGE OF INITIATION
PC
C
PA
A
M
X
ALCOHOL
X
NICOTINE
X
MARIJUANA
X
HEROIN
X
COCAINE
X
AMPHETAMINES
X
LSD
X
GAMBLING
X
EATING DISORDER
15
(No Transcript)
16
PREVENTION OF INITIATION OF ADDICTION
PC - C
C - PA
PA - A
A - M
ALREADY AFFLICTED
AT- RISK PREVENTION
POPULATION PREVENTION
17
Prevention Issues Precontemplation

• How do people stay in precontemplation for
  initiating addictive behaviors?
• Precontemplation by default or decision
• Are all negative messages about the problem
  behavior beneficial for precontemplators?
• Can too negative an attitude pose problems? Does
  advocacy against a substance protect?

18
Decisional Balance Worksheet
NO CHANGE PROS (Behavior) _______________ _______
________ _______________ CONS
(Change) _______________ _______________ _________
______
CHANGE CONS (Behavior) _______________ __________
_____ _______________ PROS (Change) ____________
__________________ _______________
19
Contemplation Challenges for Prevention

• Developing a decision balance that is tipped
  against experimentation
• Developing a decisional balance that is tipped
  against continued use after experimentation has
  happened
• Creating a decision and mindset that confirms
  disinterest and supports competing interests and
  rewards
• Opening consideration without creating interest

20
Signs of Preparation Stage Activity

• Engagement in the behavior becomes more frequent
• There is openness to the new behavior
• Expectations about the new behavior become more
  positive
• There is a developing commitment to engage
• The logistics to support the new behavior are put
  in place

21
Prevention in the Preparation Stage

• How to disrupt a developing interest and
  attachment to a new behavior
• Interfering in planning and preparation
• Creating diversions and other competing interests
  and concerns
• Undermining expectations about the new behavior

22
Preventing the firm establishment of a New
Behavior Pattern

• Increase costs of the new behavior
• Create conflicting interests and goals
• Disrupt the pattern
• Interfere with the development of the supportive
  network of users
• Undermine positive expectancies and point out the
  negatives of the new pattern of behavior

23
Maintenance and Dependence

• Once the pattern is well established, it
  continues despite negative experiences or
  consequences
• Psychological patterns and pharmacological
  effects combine to create a durable new behavior
• Social and other systems are created to support
  the new behavior pattern

24
Prevention and Relapse

• Once an individual is in Action or Maintenance,
  prevention of addiction works to create relapse,
  to break the new pattern, to develop early
  interventions that can disrupt the addiction
• Consequences can deter the firm establishment of
  some new behaviors
• At some point the focus shifts from preventing
  initiation to promoting Cessation and Recovery

25
Prevention Interventions

• Shift strategies for different stage subgroups
• Focus on the context of change and not simply the
  addictive behavior in order to build key
  protective factors or reduce critical risk
  factors for movement through stages of initiation
• Create policies that are stage-based and
  sensitive to stage transitions

26
Myths of Prevention

• The On/Off Myth
• Negative messages and demonizing drugs are the
  best prevention messages
• Schools are the best place to do prevention
• All addictive behaviors are completely linked or
  totally independent

27
Key Issues In Prevention

• Know where individuals are in the process of
  initiation
• Resist prevention myths
• Create credible messages that do more good than
  harm
• Target individuals in preparation and action
  stages who are at highest risk for initiation
• Realize that each person can be in different
  stages for multiple problematic or positive
  behaviors

28
THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Sustained Cessation
Dependence
RECOVERY
29
Theoretical and practical considerations related
to movement through the Stages of RECOVERY
Motivation Decision-Making
Self-efficacy
Precontemplation Contemplation
Preparation Action Maintenance
Personal Environmental Decisional
Cognitive Behavioral Concerns
Pressure Balance Experiential
Processes (Pros
Cons) Processes Recycling
Relapse
30
The Well-Maintained Addiction

• Defining action and maintenance is critical for
  initiation of health risks, like addiction, as
  well as health protection behaviors
• Regular, dependent use of a substance that
  creates creates a pattern that eludes
  self-regulatory control, continues despite
  negative feedback, and becomes an integral part
  of the individuals life and coping

31
Stage of Change Tasks

• Precontemplation
• Not interested
• Contemplation
• Considering
• Preparation
• Preparing
• Action
• Initial change
• Maintenance
• Sustained change

• Interested and Concerned
• Risk-Reward Analysis Decision making
• Commitment Creating an Effective/Acceptable
  Plan
• Implementation of Plan and Revising as Needed
• Consolidating Change into Lifestyle

32
Assisting Precontemplators

• Address smoking whenever possible in any health
  setting.
• Raise awareness with self-help or motivational
  materials
• Offer grounded advice to quit without nagging
• Brief motivational counseling.
• Nonjudgmental approach.
• Address barriers.
• Identify resistance.
• Check in with them periodically
• Offer hope for successful change

33
Motivating a Decision to Make a Quit Attempt

• Personally relevant health and risk education
• Point out links to current and future illness
• Explore motivations and values
• Unambiguous advice to quit
• Address patient fears
• Offer opportunities to sample cessation (e.g.
  Great American Smoke-Out, smoke-free places)

34
Beneficial Effects of Smoking to the User

• Emotional
• Anxiety, stress, depression management
• Cognitive
• Learning and memory facilitation
• Concentration and performance
• Behavioral
• Appetite and weight control
• Physiological
• Alleviates withdrawal symptoms

35
Preparation - Getting Ready to Make a Change

• Help the smoker strengthen commitment and
  motivation for change
• Help the smoker find a change strategy that is
  acceptable, accessible, and effective
• Help the smoker make choices and commit to a plan
  and strategy

36
Selecting a Treatment Triage Guidelines

• Steer patient to most appropriate treatment.
• Patient characteristics and preference.
• Minimal self-help interventions are a good place
  to start for many smokers.
• More intensiveif patient has made many prior
  attempts, is high on nicotine dependence and is
  ready and willing.
• Treatment matching.
• Tailored materials.
• Pharmacological aids

37
Use of Pharmacotherapy

• High nicotine dependence
• Smoke within 15-30 minutes after arising.
• Previous failure related to withdrawal symptoms
• Current options
• Transdermal nicotine (patch)
• Nicotine polacrilex (gum)
• Nicotine nasal spray or inhaler
• Non-nicotinic medications
• Buproprion (Zyban) or Nortriptyline
• Veranacline

38
Regression, Relapse and Recycling through the
Stages

• Regression represents movement backward through
  the stages
• Slips are brief returns to the prior behavior
  that represent a failure in the action plan
• Relapse is a re-engaging to a significant degree
  in the previous behavior after some initial
  success
• After returning to the prior behavior,
  individuals Recycle back into pre-action stages
  (precontemplation, contemplation, or preparation)
  and may feel like failures and discouraged about
  ability to change

39
(No Transcript)
40
Relapse and Recycling - Slipping Back to Previous
Behavior and Trying to Resume Change

• Treatment Goals and Strategies
• Acknowledge the reality of recycling
• Assure client that slips and relapses are normal
  and can be overcome
• Help reframe slips into learning experiences
• Help client avoid becoming discouraged or
  demoralized
• Help client renew determination and confidence in
  order to resume change efforts

41
(No Transcript)
42
Cyclical Model for Intervention

• Most smokers will recycle through multiple quit
  attempts and multiple interventions.
• However successful cessation occurs for large
  numbers of smokers over time.
• Keys to successful recycling
• Persistent efforts
• Repeated contacts
• Helping the smoker take the next step
• Bolster self-efficacy and motivation
• Match strategy to patient stage of change

43
(No Transcript)
44
Approaches that Pay Attention to the Process of
Change

• Clearly identify the target behavior
• Evaluate stage of readiness to change
• Evaluate beliefs and practices related to target
  behavior
• Examine routes and mechanisms of influence in the
  culture and for the individual
• Create sensitive stage based multi-component
  interventions
• Re-evaluate regularly the process of change

45
THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Sustained Cessation
Dependence
RECOVERY