typically do not receive adequate treatment for tobacco use (Doolan and Froelicher, 2008), but they too benefit from a variety of tobacco-cessation treatments, including those used for low-SES tobacco users. Buddy support, tailored self-help materials, and physician advice are also effective (Fiore et al., 2008). Effective interventions for racial and ethnic minorities include medications (bupropion SR and nicotine patches), motivational counseling, clinician advice, tailored self-help materials, telephone counseling, and biomedical feedback (Fiore et al., 2008).

Heavy smokers are those who smoke more than 1 pack of cigarettes a day (20 cigarettes in a pack), typically 25–30 cigarettes/day. The number of cigarettes smoked per day can be predictive of withdrawal symptoms. For people with severe tobacco dependence, it may be necessary to increase the dose of cessation medications to alleviate symptoms or to use combinations of treatments (Dale et al., 1995)—perhaps three or more medications simultaneously (Ebbert et al., 2007b). The committee recommends that health-care providers consider tailoring the dose of NRT and the use of multiple NRTs or other combination medications in these patients.

Finding: Although most studies have focused on treating tobacco users in the general public, evidence suggests that special populations—such as those with mental illness, women, and those with medical comorbidities—will benefit from the same tobacco-cessation treatments, although some modifications may be necessary to avoid medical complications. A combination of tailored behavioral therapy and medication is effective for tobacco cessation in these populations.

RELAPSE-PREVENTION INTERVENTIONS

The issue of relapse from tobacco abstinence is well known but not well studied. As many as 75–80% of smokers who quit tobacco use will relapse within 6 months (Carmody, 1992). Most people who quit without assistance relapse within the first 8 days after quitting (Hughes et al., 2004). Studies of people who used nicotine medications to quit suggest that long-term (1-year) abstinence rates are about 10% and that the rate of relapse after 1 year is not significant (Hughes et al., 2008). Several factors may be at play in relapse, including the biologic nature of nicotine addiction, conditioned activities (such as smoking when drinking alcohol or coffee), and cognitive-social learning factors. Men and women may be concerned about gaining weight if they stop smoking (Carmody, 1992; Clark et al., 2004, 2005, 2006b). A Cochrane review of



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