Relapse is common, especially in the immediate post-quitting period. Smoking for many people can be regarded as a chronic relapsing disorder, and many smokers may need repeated assistance over the course of their lifetime.1 A longitudinal study in the US spanning 25 years found that among young adults, relapse after quitting was common, with more than a third of smokers relapsing at least once. Relapse was especially likely among those with lower education level.2
There is emerging evidence that while smoking for enjoyment can deter quit attempts, such enjoyment does not predict relapse.3, 4 Cue-driven impulses to smoke, the need for nicotine, adverse moods, and beliefs about the costs and benefits of smoking are important in relapse (see Section 7.7). Relapse prevention efforts should therefore address each of these factors.3
In observing patterns of smoking that occur after quitting, some studies distinguish between a lapse (i.e., at least one puff) and full relapse (i.e., a return to regular smoking).5 Most lapses lead to relapses,5-8 and it is common for there to be a period of intermittent smoking before full relapse occurs.9 Studies have highlighted the dynamic nature of lapse responses during smoking cessation, and suggest that declines in self-efficacy are associated with progression from one lapse to the next.10 Most lapses and relapses occur shortly after quitting,11 highlighting the importance of support during this time. Establishing early abstinence appears to be crucial to establishing longer term abstinence.12 To date, most work has focused on skills-based approaches to identify situations where relapse risk is highest (e.g. socialising with smokers while consuming alcohol) then to develop and rehearse tailored strategies to deal with them in advance.13 For some smokers, their resistance to change is a barrier to quitting. Strategies for overcoming this barrier might include encouraging openness to the possibility of change, breaking down quitting into manageable steps, reframing past failures as learning experiences, subsidising and encouraging the use of quitting aids without overstating their benefit, and encouraging personal responsibility for change.14
One way to conceptualise the challenge of relapse prevention is to see it as three distinct tasks in becoming a non-smoker:
- To stop smoking (i.e. make a quit attempt).
- To learn to deal with cravings and other withdrawal symptoms without relapsing.
- To learn to enjoy and value a smokefree lifestyle, which involves facing old smoking situations without cigarettes, finding new behaviours to substitute for the perceived benefits of smoking, realising that many supposed benefits were illusory, and adopting a new non-smoker self-image.15
Given the chronic nature of nicotine dependence, along with the high likelihood of relapse among those attempting cessation, several studies have explored whether substantially extending the length of interventions could improve quitting outcomes by better aligning with the nature of addiction. Research in the US found that longitudinal care for one year promoted higher rates of long-term abstinence than standard care among participants who did not initially respond to treatment (i.e., were still smoking after 21 days), reflecting a potential care path for smokers who have initial difficulty quitting.16 Extended telephone contact or booster sessions with counsellors, GPs or other support sources have been used extensively and these have been found to have some modest effect on increasing long-term cessation.6 There is some evidence that extended (20-week) cognitive behavioural therapy may help smokers to maintain abstinence in the longer term.17
A 2010 review found that self-help materials appeared to prevent relapse in initially unaided quitters, and found positive results for the use of pharmacotherapies but no definitive evidence regarding behavioural support.18 A more comprehensive review published in 2013 concluded that there is not enough evidence to support the use of any specific behavioural intervention to help smokers avoid relapse. The majority of studies had tested interventions that taught smokers skills in identifying and managing temptations, but these were not found to be effective. In regards to cessation medications, the review found that extended treatment with varenicline may be helpful. The authors highlight the urgent need for studies of extended treatment with nicotine replacement.19
Some common approaches for relapse prevention are outlined below.
7.8.1 Keeping motivation top of mind
Although motivation seems as if it would be an important factor in quitting, and is indeed strongly predictive of making quit attempts, it does not seem to predict sustained cessation.20, 21 While motivation is needed to prompt action to stop smoking, it is not sufficient on its own to maintain cessation.21 This is likely because the determinants of motivation differ before and after a quit attempt. Before an attempt, thinking about the pros and cons of quitting and making estimates of the outcome of the attempt influences decision-making and stimulates trying.22 However, once the person has actually quit, the main determinants of motivation to stay quit are the experiences he or she is having, something people are poor at estimating in advance.23, 24
The key difficulty of motivation in the context of overcoming addiction is that there are counteracting urges and motivations to keep smoking. One way of viewing quitting is as a triumph of rationality over transient desires that are distorted by learned responses and habits associated with addiction. For most smokers, getting to the point of wanting to quit presents a formidable challenge, and there is a strong argument for encouraging and assisting smokers to quit even though they may not have resolved all doubts about quitting.22
Smokers often see their own strength of motivation or will power as being the key to successful quitting, with the implication that they are inadequate if they seek help from others, or if they fail.22, 25 Successful quitters are often perceived as more motivated, while those who relapse are less motivated. However such an analysis does not consider that motivation is a complex, multidimensional concept.
Theories of smoking cessation include a number of elements that can be used to describe motivation.23 In simple terms, motivation is directed action. Motivation is needed for the pursuit of goals, and requires energy, wanting, drive or activity in order to overcome obstacles to achieving these goals. Motivation to quit and stay quit is characterised by ambivalence and conflict, which ebbs and flows as negative thoughts about smoking compete with urges to smoke. Working to resolve this ambivalence may be helped by intrinsic and extrinsic factors: intrapersonal factors such as self-efficacy (belief that one can quit), self-competence, better health, and being a better role model, or environmental factors such as money and social approval. In the self-regulation model, motivation refers to maintaining an optimal state or system balance: if people feel good or neutral then they will maintain their behaviour. Smoking cessation usually results in temporary unpleasant moods, so it is necessary to use coping strategies to avoid returning to smoking. Feedback loops on how behaviour affects mood is an important motivational mechanism: negative affect (unpleasant moods) predicts relapse, but effective coping to decrease negative affect helps maintain cessation.23
Motivational interviewing is a person-centered, goal-oriented style of counselling, which aims to elicit and strengthen people's own motivation and commitment towards behaviour change by helping them resolve their ambivalence and evoking their reasons for change.26 This approach is widely used to help people to quit smoking.27 Common components of motivational interviewing include: exploring ambivalence, decision balance (i.e., weighing pros and cons), assessment of motivation and confidence to quit, eliciting ‘change talk’ (i.e., statements that indicate the person has the desire, motivation, and/or commitment to change their behaviour), and supporting self-efficacy.27
A 2015 Cochrane review concluded that motivational interviewing may assist people to quit smoking, and appears to help more people to quit than brief advice or usual care when provided by general practitioners (GPs) and by trained counsellors. Shorter motivational interviewing sessions (less than 20 minutes per session) were more effective than longer ones. A single session of treatment appeared to be marginally more successful than multiple sessions, but both delivered successful outcomes. The evidence for the value of follow-up telephone support was unclear, and face-to-face counselling was no more helpful than telephone counselling. Both approaches were more successful than brief advice or usual care.27
7.8.2 Anticipating and coping with triggers (stress and mood changes, social pressure and alcohol)
The most widely studied interventions for preventing relapse have used skills building approaches, whereby people learn to identify high-risk situations and are provided with cognitive and behavioural strategies to cope with these situations. A 2013 Cochrane review found that the evidence does not support the effectiveness of this approach, however highlighted that although it may indeed be ineffective, findings could also be due to such skills not being taught effectively. The authors recommend that future studies should try to ascertain whether participants successfully acquired and practised the relevant skills.19
7.8.2.1 Temporary changes in routine
Based on classical conditioning theory, many smoking cessation support services suggest temporary changes in routine and habits that are associated with smoking as a strategy to minimise exposure to smoking cues (see Section 7.3). Smokers commonly smoke when they drink alcohol, and drinking is related to relapse in smoking cessation attempts.28, 29 One study found that alcohol can reduce the ability to resist smoking in a dose-dependent fashion (i.e., the more alcohol that is consumed, the less a person can resist smoking), partly due to its effect on increasing the intensity of smoking urges.30 Therefore, avoiding situations that involve drinking can be helpful in maintaining abstinence from smoking.
7.8.2.2 Dealing with stress and mood disturbance
People attempting to quit tend to relapse not only due to their level of addiction, but also due to immediate precursor factors such as emotional distress.31 Given the association between negative affect following cessation and risk of relapse, strategies that enhance impulse control and help the person to manage negative emotions without the use of cigarettes may help to promote sustained cessation.32 One study found that the inclusion of a mood-management tool in an internet-based cessation intervention increased quitting outcomes.33 Compared to continuing smokers, successful quitters experience improved wellbeing and happiness, which could be communicated to smokers to increase their motivation to quit.34, 35
7.8.3 Managing concerns about weight gain
Experiencing weight gain after quitting can be an important predictor of relapse and can deter subsequent quit attempts.36 Nicotine replacement products and bupropion appear to be modestly effective in postponing some of the weight gain that often accompanies cessation.37-40 Nicotine gum may have the potential to minimise weight gain in the long term if higher doses are used properly, more often.41 Other pharmacological interventions have shown initial weight gain reduction, but this was not maintained in the longer term.40 Advice to attenuate weight gain includes engaging in physical activity, having a healthy diet and limiting alcohol consumption;38, 39 42-46 however, such advice does not appear to reduce weight gain and may in fact reduce abstinence from smoking.40 Studies on simultaneous quitting and dieting to prevent weight gain have produced mixed results: some found that it undermined the attempt to quit smoking, while others reported similar or higher rates of success for smoking cessation in specific populations.39 Some researchers suggest that a self-control strength model, where self-regulation relies on limited strength that is depleted with use, may explain why dieting undermines cessation attempts.47 One study suggests that for weight-concerned female smokers, success in changing eating behaviour may increase self-efficacy for quitting smoking.48 Another study found that mindfulness (see Section 7.8.5, below) weakens the link between smoking-related weight concerns and smoking behaviour among young women.49 A systematic review and meta-analysis of behavioural interventions that promote smoking cessation and prevent weight gain concluded that while there is no evidence that such interventions produce any harm and significant evidence of short-term (less than three months) benefit for both abstinence and weight control, research to date does not show long-term effectiveness.50
A 2012 Cochrane review concluded that some pharmacotherapies (bupropion, fluoxetine, NRT and varenicline) show short-term success in reducing post-cessation weight gain, but long-term evidence is limited. Personalised weight management support may be effective and not reduce abstinence, but more studies are needed. One study showed a very low calorie diet increased abstinence but did not prevent weight gain in the longer term. Ineffective interventions included weight management education, and cognitive-behavioural therapy to accept weight gain. Exercise interventions significantly reduced weight in the long term but not the short term, but further studies are needed to clarify this relationship. Overall, there was not enough data to make strong clinical recommendations.51
7.8.4 Managing cravings
The management of cravings, which are typically most intense within the first few days after quitting, is complicated by the high variability in symptoms across individuals and time, as well as by the lack of a definitive number or severity of symptoms that lead to relapse.52 Investigating how smokers react to the discomfort of nicotine withdrawal and quitting smoking may have important implications for developing specialised treatments.53 A number of studies support the use of exercise to help decrease cravings to smoke,54, 55 and acute exercise may provide additional craving relief on top of that provided by NRT in recently quit smokers.56
7.8.4.1 Distractions
Distractions, together with breathing exercises and eating/drinking, are among the most commonly used techniques to cope with cravings to smoke.57 For example, researchers in the UK found that playing Tetris significantly decreases cigarette cravings in real-world settings. They explained that craving involves imagining the experience of consuming a particular substance, and playing Tetris (a visually interesting game) occupies the mental processes that support that imagery. It is difficult to imagine something vividly (i.e., crave it) and play Tetris at the same time.58 Researchers have also started to explore the use of mobile phone apps as a source of distraction during cigarette cravings.59
7.8.4.2 Medication to reduce cravings and other withdrawal symptoms
Smoking cessation medications primarily aim to reduce withdrawal symptoms and block the reinforcing effects of nicotine.60 Pharmacotherapies may be particularly helpful for more dependent smokers, and are effective for increasing smoking abstinence rates, at least in the short term.61, 62 However, a systematic review of relapse prevention strategies found that there is substantial relapse to smoking after drug treatment courses are finished.63 A 2013 Cochrane review found that extended treatment with varenicline may prevent relapse, but extended treatment with bupropion is unlikely to have a clinically important effect.19 Nonetheless, economic analyses of the use of pharmacotherapies for cessation suggest they are highly cost effective.63, 64 (See Section 7.16 and Chapter 17 for more detailed information on pharmacotherapies.)
7.8.5 Social support
Some findings suggest that social support affects relapse. Limited evidence indicates that a high percentage of partners are willing to help their partner who smokes and are interested in learning ways to help.65 However a 2012 Cochrane review of interventions designed to enhance partner support for smokers in cessation programs failed to detect an increase in quit rates, but highlighted that more research is needed to adequately explore the effects of partner support interventions for smoking cessation.66 An analysis of combined data from three randomised clinical trials found that positive social support predicted success in the early phase of quitting, while the absence of unhelpful and negative behaviours (such as expressing doubt and nagging) from important others best predicted maintained abstinence.67
7.8.6 Mindfulness
The concept of mindfulness has roots in Buddhist and other contemplative traditions. It is often described as the state of being attentive to and aware of what is taking place in the present.68 Mindfulness is an inherent human capability that can be learned and trained, and its practice has been linked with a range of improved health outcomes.69 It allows people to reduce their negative and increase their positive affect, and improve their overall wellbeing.70
A growing body of research supports the effectiveness of mindfulness-based interventions for smoking cessation. Smokers, especially female smokers, have lower levels of mindfulness and wellbeing than non-smokers, leading researchers to suggest that mindfulness-based interventions may help smokers to deal with treatment and abstinence by increasing their level of wellbeing.70 Mindfulness strategies for managing nicotine cravings involve present-moment, nonjudgemental awareness of cravings without acting on them.71
A review of addiction research found that exercises aimed at increasing self-control, such as mindfulness meditation, can decrease the unconscious influences that cause cigarette cravings. For example, one study showed that mindfulness meditation training led to a subconscious reduction in smoking. Although participants who had completed the training reported smoking the same number of cigarettes, an objective measure of carbon dioxide percentage in their lungs suggested a 60 per cent reduction in quantity of smoke inhaled over two weeks after the study.72 Researchers in the US found that mindfulness training led to significantly higher abstinence rates among a group of socioeconomically disadvantaged smokers.73 Mindfulness practice appears to reduce negative affect, craving, and cigarette use among smokers who are trying to quit.74 A 2015 systematic review concluded that mindfulness-based interventions show promise for the treatment of smoking, especially for cessation, relapse prevention, number of cigarettes smoked, moderating the relationship between craving and smoking, and the development of coping strategies to deal with triggers to smoke. The positive effects of mindfulness on mental health might contribute to the maintenance of tobacco abstinence.75
Relevant news and research
For recent news items and research on this topic, click here.(Last updated March 2023)
References
1. Fiore MC and Jaén CR. A clinical blueprint to accelerate the elimination of tobacco use. Journal of the American Medical Association, 2008; 299(17):2083–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18460668
2. Caraballo RS, Kruger J, Asman K, Pederson L, Widome R, et al. Relapse among cigarette smokers: The CARDIA longitudinal study–1985–2011. Addictive Behaviors, 2014; 39(1):101–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24172753
3. West R. The multiple facets of cigarette addiction and what they mean for encouraging and helping smokers to stop. Journal of Chronic Obstructive Pulmonary Disease, 2009; 6(4):277–83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19811387
4. Yong H-H and Borland R. Functional beliefs about smoking and quitting activity among adult smokers in four countries: Findings from the International Tobacco Control Four country survey. Health Psychology, 2008; 27(3 0):S216–S23. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4600630/
5. Piasecki T. Relapse to smoking. Clinical Psychology Review, 2006; 26(2):196–215. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16352382
6. Ockene J, Emmons K, Mermelstein R, Perkins K, Bonello D, et al. Relapse and maintenance issues for smoking cessation. Health Psychology, 2000; 19(1 Suppl):17–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10709945
7. Shadel W, Martino S, Setodji C, Cervone D, Witkiewitz K, et al. Lapse-induced surges in craving influence relapse in adult smokers: An experimental investigation. Health Psychology, 2011; 30(5):588–96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21574708
8. Brandon T, Tiffany S, Obremski K, and Baker T. Postcessation cigarette use: The process of relapse. Addictive Behaviors, 1990; 15(2):105–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2343783
9. Shiffman S, Hickox M, Paty J, Gnys M, Kassel J, et al. Progression from a smoking lapse to relapse: Prediction from abstinence violation effects, nicotine dependence, and lapse characteristics. Journal of Consulting Clinical Psychology, 1996; 64(5):993–1002. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8916628
10. Kirchner T, Shiffman S, and Wileyto E. Relapse dynamics during smoking cessation: Recurrent abstinence violation effects and lapse-relapse progression. Journal of Abnormal Psychology, 2011; 121(1):187–97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21787035
11. Hughes JR, Keely J, and Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction, 2004; 99(1):29–38. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14678060
12. Romanowich P and Lamb R. The relationship between in-treatment abstinence and post-treatment abstinence in a smoking cessation treatment. Experimental and Clinical Psychopharmacology, 2010; 18(1):32–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20158292
13. Haaga D. Issues in relating self-efficacy to smoking relapse: Importance of an "Achilles' heel" situation and of prior quitting experience. Journal of Substance Abuse Treatment, 1990; 2(2):191–200. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2136109
14. Segan CJ, Borland R, and Greenwood KM. Do transtheoretical model measures predict the transition from preparation to action in smoking cessation? Psychology and Health, 2002; 17(4):417–35. Available from: http://www.tandfonline.com/doi/abs/10.1080/0887044022000004911
15. Segan C, Borland R, Hannan A, and Stillman S. The challenge of embracing a smoke-free lifestyle: A neglected area in smoking cessation programs. Health Education Research, 2006; 23(1):1–9. Available from: http://her.oxfordjournals.org/cgi/content/abstract/23/1/1?etoc
16. Burns RJ, Rothman AJ, Fu SS, Lindgren B, Vock DM, et al. Longitudinal care improves cessation in smokers who do not initially respond to treatment by increasing cessation self-efficacy, satisfaction, and readiness to quit: A mediated moderation analysis. Annals of Behavioral Medicine, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26373657
17. Killen JD, Fortmann SP, Schatzberg AF, Arredondo C, Murphy G, et al. Extended cognitive behavior therapy for cigarette smoking cessation. Addiction, 2008; 103(8):1381–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18855829
18. Agboola S, Coleman T, Leonardi-Bee J, McEwen A, and McNeill A. Provision of relapse prevention interventions in UK NHS stop smoking services: A survey. BMC Health Services Research, 2010; 10:214. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20646297
19. Hajek P, Stead LF, West R, Jarvis M, Hartmann-Boyce J, et al. Relapse prevention interventions for smoking cessation. The Cochrane Library, 2013. Available from: http://dx.doi.org/10.1002/14651858.CD003999.pub4
20. Hyland A, Borland R, Li Q, Yong HH, McNeill A, et al. Individual-level predictors of cessation behaviours among participants in the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 2006; 15(suppl. 3):iii83–94. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/suppl_3/iii83
21. Borland R, Yong H, Balmford J, Cooper J, Cummings K, et al. Motivational factors predict quit attempts but not maintenance of smoking cessation: Findings from the International Tobacco Control Four country project. Nicotine & Tobacco Research, 2010; 12 Suppl:S4–S11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20889479
22. Balmford J and Borland R. What does it mean to want to quit? Drug and Alcohol Review, 2008; 27(1):21–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18034378
23. Nezami E, Sussman S, and Pentz M. Motivation in tobacco use cessation research. Review. Substance Use & Misuse, 2003; 38(1):25–50. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12602805
24. Dijkstra A, Borland R, and Buunk BP. The motivation to stay abstinent in ex-smokers: Comparing the present with the past. Addictive Behaviors, 2007; 32(10):2372–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17408869
25. Carter S, Borland R, and Chapman C. Finding the strength to kill your best friend–smokers talk about smoking and quitting. Sydney: Australian Smoking Cessation Consortium and GlaxoSmithKline Consumer Healthcare, 2001. Available from: http://tobacco.health.usyd.edu.au/site/supersite/resources/pdfs/killbestfriend.pdf
26. Miller WR and Rollnick S, Motivational interviewing: Helping people change. 3rd ed. New York: Guilford Publications; 2012. Available from: http://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274
27. Lindson-Hawley N, Thompson TP, and Begh R. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews, 2015; 3:CD006936. Available from: http://dx.doi.org/10.1002/14651858.CD006936.pub3
28. Lisha NE, Carmody TP, Humfleet GL, and Delucchi KL. Reciprocal effects of alcohol and nicotine in smoking cessation treatment studies. Addictive Behaviors, 2014; 39(3):637–43. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24333039
29. Lam CY, Businelle MS, Aigner CJ, McClure JB, Cofta-Woerpel L, et al. Individual and combined effects of multiple high-risk triggers on postcessation smoking urge and lapse. Nicotine & Tobacco Research, 2014; 16(5):569–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24323569
30. Kahler CW, Metrik J, Spillane NS, Day A, Leventhal AM, et al. Acute effects of low and high dose alcohol on smoking lapse behavior in a laboratory analogue task. Psychopharmacology (Berl), 2014; 231(24):4649–57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24858377
31. Gokbayrak NS, Paiva AL, Blissmer BJ, and Prochaska JO. Predictors of relapse among smokers: Transtheoretical effort variables, demographics, and smoking severity. Addictive Behaviors, 2015; 42:176–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25481450
32. Yong H, Borland R, Cooper J, and Cummings K. Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine & Tobacco Research, 2010; 12 Suppl:S12–S9. Available from: http://ntr.oxfordjournals.org/content/12/suppl_1/S12.long
33. Branstrom R, Penilla C, Perez-Stable E, and Munoz R. Positive affect and mood management in successful smoking cessation. American Journal of Health Behavior, 2010; 34(5):553–62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20524885
34. Piper M, Schlam T, Cook J, Sheffer M, Smith S, et al. Tobacco withdrawal components and their relations with cessation success. Psychopharmacology, 2011; 216(4):569–78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21416234
35. Shahab L and West R. Differences in happiness between smokers, ex-smokers and never smokers: Cross-sectional findings from a national household survey. Drug and Alcohol Dependence, 2011; 121(1–2):38–44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21906891
36. Veldheer S, Yingst J, Foulds G, Hrabovsky S, Berg A, et al. Once bitten, twice shy: Concern about gaining weight after smoking cessation and its association with seeking treatment. International Journal of Clinical Practice, 2014; 68(3):388–95. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24471797
37. US Department of Health and Human Services. Reducing tobacco use: A report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2000/complete_report/index.htm
38. Fiore M, Bailey W, and Cohen S, et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville MD: US Department of Health and Human Services. Public Health Service., 2000. Available from: http://www.treatobacco.net/fr/uploads/documents/Treatment%20Guidelines/USA%20treatment%20guidelines%20in%20English%202000.pdf
39. Filozof C, Fernandez Pinilla MC, and Fernandez-Cruz A. Smoking cessation and weight gain. Obesity Reviews, 2004; 5(2):95–103. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15086863
40. Parsons A, Lycett D, and Aveyard P. Behavioural interventions to prevent weight gain on smoking cessation: A response. Addiction, 2009; 104(12):2119–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19922579
41. Nordstrom B, Kinnunen T, Utman C, and Garvey E. Long-term effects of nicotine gum on weight gain after smoking cessation. Nicotine & Tobacco Research, 1999; 1(3):259–66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11072423
42. Froom P, Melamed S, and Benbassat J. Smoking cessation and weight gain. The Journal of Family Practice, 1998; 46(6):460–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9638109
43. Pisinger C and Jorgensen T. Waist circumference and weight following smoking cessation in a general population: The inter99 study. Preventive Medicine, 2007; 44(4):290–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17222450
44. Swan GE and Carmelli D. Characteristics associated with excessive weight gain after smoking cessation in men. American Journal of Public Health, 1995; 85(1):73–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7832265
45. Kawachi I, Troisi RJ, Rotnitzky AG, Coakley EH, and Colditz GA. Can physical activity minimize weight gain in women after smoking cessation? American Journal of Public Health, 1996; 86(7):999–1004. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8669525
46. Marcus B, Albrecht A, King T, Parisi A, Pinto B, et al. The efficacy of exercise as an aid for smoking cessation in women: A randomized controlled trial. Archives of Internal Medicine, 1999; 159(11):1229–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10371231
47. Shmueli D and Prochaska J. Resisting tempting foods and smoking behavior: Implications from a self-control theory perspective. Health Psychology, 2009; 28(3):300–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19450035
48. Sallit J, Ciccazzo M, and Dixon Z. A cognitive-behavioral weight control program improves eating and smoking behaviors in weight-concerned female smokers. Journal of the American Dietetic Association, 2009; 109(8):1398–405. Available from: http://www.adajournal.org/article/PIIS0002822309006312/fulltext
49. Adams CE, McVay MA, Stewart DW, Vinci C, Kinsaul J, et al. Mindfulness ameliorates the relationship between weight concerns and smoking behavior in female smokers: A cross-sectional investigation. Mindfulness, 2014; 5(2):179–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24778746
50. Spring B, Howe D, Berendsen M, McFadden H, Hitchcock K, et al. Behavioral intervention to promote smoking cessation and prevent weight gain: A systematic review and meta-analysis. Addiction, 2009; 104(9):1472–86. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19549058
51. Farley AC, Hajek P, Lycett D, and Aveyard P. Interventions for preventing weight gain after smoking cessation. Cochrane Database of Systematic Reviews, 2012. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006219.pub3/abstract
52. Allen S, Bade T, Hatsukami D, and Center B. Craving, withdrawal, and smoking urges on days immediately prior to smoking relapse. Nicotine & Tobacco Research, 2008; 10(1):35–45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18188743
53. Brown R, Lejuez C, Strong D, Kahler C, Zvolensky M, et al. A prospective examination of distress tolerance and early smoking lapse in adult self-quitters. Nicotine & Tobacco Research, 2009; 11(5):493–502. Available from: http://ntr.oxfordjournals.org/cgi/content/full/11/5/493
54. Elibero A, Janse Van Rensburg K, and Drobes D. Acute effects of aerobic exercise and hatha yoga on craving to smoke. Nicotine & Tobacco Research, 2011; 13(11):1140–8. Available from: http://ntr.oxfordjournals.org/content/early/2011/08/17/ntr.ntr163.full
55. Fong AJ, De Jesus S, Bray SR, and Prapavessis H. Effect of exercise on cigarette cravings and ad libitum smoking following concurrent stressors. Addictive Behaviors, 2014; 39(10):1516–21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24971700
56. Tritter A, Fitzgeorge L, and Prapavessis H. The effect of acute exercise on cigarette cravings while using a nicotine lozenge. Psychopharmacology, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25701265
57. O'Connell KA, Gerkovich MM, Cook MR, Shiffman S, Hickcox M, et al. Coping in real time: Using ecological momentary assessment techniques to assess coping with the urge to smoke. Research in Nursing & Health, 1998; 21(6):487–97. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9839794
58. Skorka-Brown J, Andrade J, Whalley B, and May J. Playing tetris decreases drug and other cravings in real world settings. Addictive Behaviors, 2015; 51:165–70. Available from: http://www.sciencedirect.com/science/article/pii/S0306460315002762
59. Ploderer B, Smith W, Pearce J, and Borland R. A mobile app offering distractions and tips to cope with cigarette craving: A qualitative study. JMIR Mhealth Uhealth, 2014; 2(2):e23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25099632
60. Jiloha RC. Pharmacotherapy of smoking cessation. Indian Journal of Psychiatry, 2014; 56(1):87–95. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3927255/
61. Mills E, Wu P, Spurden D, Ebbert J, and Wilson K. Efficacy of pharmacotherapies for short-term smoking abstinance: A systematic review and meta-analysis. Harm Reduction Journal, 2009; 6:25. Available from: http://www.harmreductionjournal.com/content/6/1/25
62. Fant RV, Buchhalter AR, Buchman AC, and Henningfield JE. Pharmacotherapy for tobacco dependence. Handbook of Experimental Pharmacology, 2009; (192):487–510. Available from: http://www.springerlink.com/content/t3v711x3n7224242/
63. Coleman T, Agboola S, Leonardi-Bee J, Taylor M, McEwen A, et al. Relapse prevention in UK stop smoking services: Current practice, systematic reviews of effectiveness and cost-effectiveness analysis. Health Technology Assessment, 2010; 14(49):1– 52, iii–iv. Available from: http://www.hta.ac.uk/execsumm/summ1449.htm
64. Taylor M, Leonardi-Bee J, Agboola S, McNeill A, and Coleman T. Cost effectiveness of interventions to reduce relapse to smoking following smoking cessation. Addiction, 2011; 106(10):1819–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21561499
65. Thomas J, Patten C, Mahnken J, Offord K, Hou Q, et al. Validation of the support provided measure among spouses of smokers receiving a clinical smoking cessation intervention. Psychology, Health & Medicine, 2009; 14(4):443–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19697254
66. Park EW, Tudiver FG, and Campbell T. Enhancing partner support to improve smoking cessation. The Cochrane Library, 2012. Available from: http://dx.doi.org/10.1002/14651858.CD002928.pub3
67. Lawhon D, Humfleet GL, Hall SM, Munoz RF, and Reus VI. Longitudinal analysis of abstinence-specific social support and smoking cessation. Health Psychology, 2009; 28(4):465–72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19594271
68. Brown KW and Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 2003; 84(4):822–48. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12703651
69. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 2003; 10(2):125–43. Available from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0020130/
70. Barros VV, Kozasa EH, Formagini TD, Pereira LH, and Ronzani TM. Smokers show lower levels of psychological well-being and mindfulness than non-smokers. PLoS ONE, 2015; 10(8):e0135377. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26270556
71. Rogojanski J, Vettese L, and Antony M. Role of sensitivity to anxiety symptoms in responsiveness to mindfulness versus suppression strategies for coping with smoking cravings. Journal of Clinical Psychology, 2011; 67(4):439–45. Available from: http://onlinelibrary.wiley.com/doi/10.1002/jclp.20774/full
72. Tang Y-Y, Posner MI, Rothbart MK, and Volkow ND. Circuitry of self-control and its role in reducing addiction. Trends in Cognitive Sciences, 2015; 19(8):439–44. Available from: http://dx.doi.org/10.1016/j.tics.2015.06.007
73. Davis JM, Goldberg SB, Anderson MC, Manley AR, Smith SS, et al. Randomized trial on mindfulness training for smokers targeted to a disadvantaged population. Substance Use and Misuse, 2014; 49(5):571–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24611852
74. Ruscio AC, Muench C, Brede E, and Waters AJ. Effect of brief mindfulness practice on self-reported affect, craving, and smoking: A pilot randomized controlled trial using ecological momentary assessment. Nicotine & Tobacco Research, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25863520
75. de Souza IC, de Barros VV, Gomide HP, Miranda TC, Menezes VP, et al. Mindfulness-based interventions for the treatment of smoking: A systematic literature review. Journal of Alternative and Complementary Medicine, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25710798