7.8 How can relapse be prevented?

Last updated: July 2023

Suggested citation: Jenkins, S., Greenhalgh, EM., Stillman, S., & Ford, C. 7.8 How can relapse be prevented? In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from http://www.tobaccoinaustralia.org.au/chapter-7-cessation/7-8-how-can-relapse-be-prevented


Smoking for many people can be regarded as a chronic relapsing disorder due to the high frequency of relapse among individuals who try to quit (see Section 7.2.3 Population trends in quit attempts and success in quitting).

Relapses commonly occur shortly after quitting, underscoring the importance of support during this period. When observing smoking patterns after quitting, certain studies differentiate between a lapse (defined as at least one puff) and a full relapse (a return to regular smoking).1 Most lapses ultimately lead to relapses,1-4 and it is common for individuals to engage in intermittent smoking before a full relapse occurs.5 Higher rates of relapse are reported by young people.6

Cue-driven impulses to smoke (e.g. stress, social events, alcohol, others smoking), withdrawal symptoms, adverse moods, concern about weight gain and other factors influence success in quitting (see Section 7.7 Environmental and biopsychosocial factors that influence quitting). Consequently, relapse prevention efforts should address these contributory factors.7

A constructive way to approach the challenge of relapse prevention is to view it as three distinct tasks in becoming a non-smoker:

  • Ceasing smoking (i.e. make a quit attempt).
  • Learning to navigate cravings and other withdrawal symptoms without relapsing.
  • Embracing a smoke-free 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.8

The remainder of this section explores strategies and interventions designed to prevent relapse among smokers:

7.8.1 Anticipating and coping with triggers Temporary changes in routine Managing stress and mood disturbance Mindfulness

7.8.2 Managing cravings Distractions Pharmacotherapies to reduce cravings and other withdrawal symptoms Exercise

7.8.3 Social support

7.8.4 Developing a non-smoker identity  

7.8.5 Managing concerns about weight gain Pharmacological interventions Behavioural interventions

Note that a variety of strategies and interventions for smoking cessation, many of which also hold potential for preventing relapse, are explored across different sections of Chapter 7.

7.8.1 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. Strategies include temporarily changing routines to avoid environmental triggers (e.g., social pressures and alcohol) and managing stress and mood disturbances, these strategies are explored in further detail below. However, a 2019 Cochrane review found moderate-certainty evidence that, despite the popularity of this approach, it provides no benefit in preventing relapse. The authors suggest that these findings could also be due to such skills not being taught effectively and recommend that future studies should try to ascertain whether participants successfully acquired and practised the relevant skills.9 Temporary changes in routine

Based on classical conditioning theory (see Section 7.3.1), 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. Smokers commonly smoke when they drink alcohol, and drinking is related to relapse in smoking cessation attempts, particularly among less dependent smokers.10-12 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.13 Another study observed that for less dependent smokers the risk of alcohol-precipitated lapses was highest in the early period of quit attempts.12 Social environments where smoking occurs may expose individuals trying to quit to smoking cues that make resisting smoking more difficult (e.g., the smell of smoke can trigger the urge to smoke).14-16Therefore, avoiding situations that involve smoking or drinking, particularly early in a cessation attempt, may help maintain abstinence from smoking. Managing 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 stress and emotional distress. 17,18 The ability to manage emotions in stressful situations also appears to play a role in relapse, as one study found higher stress reactivity was associated with relapse only among people with lower emotional repair abilities.19 (See Section for further information on the effects of mood disturbance on smoking cessation.) Given these associations, strategies that enhance impulse control and help manage negative emotions without the use of cigarettes may be beneficial for achieving sustained cessation.20 One study found that the inclusion of a mood-management tool in an internet-based cessation intervention increased quitting outcomes.21 It is also worth noting that compared to continuing smokers, successful quitters experience improved well-being and happiness, which could be communicated to smokers to increase their motivation to quit. 22,23 Mindfulness

There is also a growing body of research that supports the effectiveness of mindfulness-based interventions for smoking cessation (see Section and preventing relapse. Greater mindfulness is associated with lower perceived negative affect and reduced withdrawal symptoms among smokers,24 both of which are strong predictors of relapse (see Section 7.7). It has also been observed that higher mindfulness is indirectly associated with a lower risk of smoking lapse through lower perceived stress.25

A 2015 systematic review concluded that mindfulness-based interventions show promise for preventing relapse. Studies showed that mindfulness moderated the relationship between craving and smoking, and that the positive effects of mindfulness on mental health might contribute to the maintenance of tobacco abstinence.26 Researchers in the US also found that mindfulness training led to significantly higher abstinence rates among a group of socioeconomically disadvantaged smokers.27 A 2016 meta-analysis of randomised controlled trials found that while the cessation rate was comparable between mindfulness-based interventions and standard care interventions, at four months post-intervention more individuals who had received mindfulness training remained quit (25%) compared to those who received standard care (14%).28 While many mindfulness interventions tested in these studies are intensive (e.g. 8-weeks in duration with 2-h weekly sessions and up to 45 min of daily home practice), more feasible, brief and single-session mindfulness exercises have also demonstrated effectiveness in reducing distress, cravings, withdrawal symptoms, and changing smoking behaviours.29-31

7.8.2 Managing cravings

Experiencing craving for tobacco products has been found to be associated with smoking lapse incidence during quit attempts.32 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.33 Investigating how smokers react to the discomfort of nicotine withdrawal and quitting smoking may have important implications for developing specialised treatments.34 The existing literature has predominantly concentrated on strategies such as distraction, pharmacotherapy, and exercise to address cravings, these are detailed below. In addition to these, withdrawal regulation training has emerged as a promising strategy. Preliminary findings from a pilot study have shown encouraging results, with the training group displaying higher rates of abstinence compared to the control group.35 Distractions

Distractions, together with breathing exercises and eating/drinking, are among the most commonly used techniques to cope with cravings to smoke.36 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.37 Researchers have also started to explore the use of mobile phone apps as a source of distraction during cigarette cravings. 38,39 Pharmacotherapies to reduce cravings and other withdrawal symptoms

Smoking cessation medications primarily aim to reduce withdrawal symptoms and block the reinforcing effects of nicotine.40 Pharmacotherapies may be particularly helpful for more dependent smokers, and are effective for increasing smoking abstinence rates, at least in the short term. 41,42 ( Sections 7.16 provides more detailed information about pharmacotherapies.) However, a systematic review of relapse prevention strategies found that there is substantial relapse to smoking after drug treatment courses are finished.43 Several studies have explored whether extending the use of cessation medications could improve quitting outcomes by better aligning with the nature of addiction. A 2019 Cochrane review concluded that for people who successfully quit smoking using pharmacotherapy, there was moderate-certainty evidence that extending treatment with varenicline helped to prevent relapse. The evidence did not indicate that there was a benefit of extended treatment with bupropion or nicotine replacement therapy (NRT) in preventing relapse, though the quality of evidence was not sufficient to rule out the possibility of a benefit. However, an economic analysis of varenicline, bupropion and NRT use among recently abstinent smokers indicated that all three pharmacotherapies were cost-effective in preventing relapse.44 (See Section  for further information on the cost-effectiveness of pharmacotherapies.) Exercise

Several studies have observed reduced cravings among people who smoke after exercising.45-47  . A 2019 Cochrane review found very low‐certainty evidence that adding exercise to relapse prevention support did not improve long‐term abstinence compared with relapse prevention support alone.48 However a small trial also found that acute exercise combined with NRT provided greater craving relief than either intervention individually in recently quit smokers.49

7.8.3 Social support

Some findings suggest that social support may assist in preventing relapse. An analysis of combined data from three randomised clinical trials found that positive social support predicted success in the early phase of quitting, and the absence of unhelpful and negative support (such as expressing doubt and nagging) most strongly predicted maintained abstinence.50 Seeking support during a quit attempt may also affect relapse. A study also found that among women, seeking more support from one’s partner was associated with reduced effects of craving on smoking.51

Limited evidence indicates that a high percentage of partners are willing to help their partner who smokes to quit and are interested in learning ways to help.52 However, a 2018 Cochrane review of interventions designed to enhance partner support for smokers in cessation programs failed to detect an increase in quit rates, regardless of the length of follow-up period or relationship to the person providing support (e.g., friend vs. romantic partner etc.). Very few studies found evidence that the intervention successfully increased the support participants received from their partners, indicating that more research is needed to develop behavioural interventions that actually increase partner support.53 Subsequent studies have similarly not found that partner-assisted intervention increased quit rates.54

The smoking status of a person’s partner can also have a substantial influence on smoking cessation (see Section Couples that quit together may have greater success in sustained quitting. A retrospective study found that among participants making a quit attempt, those with a smoking partner who also stopped smoking during this time were more likely to quit than those with a non-smoking partner.55

Smoke-free home policies may also reduce relapse by reducing exposure to the smell of other people’s smoke which can trigger the urge to smoke among recent quitters.16 A US longitudinal survey found former smokers who lived in smoke-free homes had lower rates of relapse.6 ( Section 15.6 provides further information on smoke-free homes and regulation of smoking in multi-unit housing.)

7.8.4 Developing a non-smoker identity  

Adopting the identity/image of one’s self as a non-smoker could be protective from relapse. Former smokers who identify as ex-smokers, non-smokers or smokers who chose to no longer smoke, have lower relapse rates compared to those who identify as smokers trying to quit.56 Early research developing future-self interventions to strengthen non-smoking identity has not been effective in influencing in influencing participants’ smoking-related identity. Further research is needed to develop effective identity-based interventions and test their impact on cessation outcomes.57

7.8.5 Managing concerns about weight gain

Experiencing weight gain after quitting can be a predictor of relapse and can deter subsequent quit attempts. 58,59 (See Section for further information on the effect of weight gain concerns on smoking cessation.) Pharmacological and behavioural interventions to limit weight gain could be beneficial when quitting. However, a 2021 Cochrane review of existing evidence at the time concluded there was no intervention for which there is moderate certainty of a clinically useful effect on long-term weight gain. There was also no moderate- or high-certainty evidence that weight gain prevention interventions could reduce people’s likelihood of smoking abstinence. The review did find some, albeit in many cases limited, evidence that certain pharmacological and behavioural interventions may have some beneficial effects on weight gain in the short term.60

An overview of the effect of smoking cessation on weight gain is provided in Section Pharmacological interventions

The 2021 Cochrane review found high-certainty evidence that the cessation medication, varenicline modestly reduced weight at the end of treatment. There was also moderate-certainty evidence that nicotine replacement therapy (NRT) reduced weight at the end of treatment. For bupropion and fluoxetine there was low- and very-low certainty evidence, respectively, that these medications limited weight gain at the end of treatment. The long-term effect estimates of varenicline, NRT and bupropion on weight gain were imprecise and in the case of fluoxetine, there was no data available. There was evidence that some other medications for weight loss and addiction treatment (dexfenfluramine, phenylpropanolamine, naltrexone) were associated with reduced weight gain at the end of treatment, though there was not evidence indicating these medications reduced weight gain in the long term.60 There is minimal research into the use of a combination of weight-loss medications and varenicline for preventing post-cessation weight gain, but this could be a potential avenue for future research to explore.61 Behavioural interventions

Behavioural interventions for preventing weight gain during smoking cessation include weight-management education programs, exercise, acceptance-based treatment, dieting, advice, exercise and physical activity counselling. A 2023 meta-analysis of behavioural interventions for smoking cessation that also address post-cessation weight gain concluded that there was evidence that such interventions enhance smoking abstinence in the short term. However, similar to the findings of the 2021 Cochrane review,60 there was not evidence that these interventions improved abstinence in the long term or weight gain in the short or long term.62

Personalised weight‐management support programmes for smoking cessation incorporate education, feedback on personal goals and a personal energy prescription. The 2021 Cochrane review found very low-certainty evidence that personalised weight‐management support programmes reduce weight gain at end of treatment but no evidence for an effect at 12-month follow-up. Alternatively, when considering weight management education without personalisation there was low certainty evidence that it did not reduce weight and very-low certainty evidence that it may have reduced smoking cessation rates.60  

The review also found low-certainty evidence that exercise interventions reduced weight gain at 12-month follow-up, however at end of treatment there was low-certainty evidence that exercise interventions did not affect weight.60

The review also found low-certainty evidence that acceptance inventions designed to allay participants’ concerns about weight-gain may increase abstinence at 6-months but not at 12 months. The effect of acceptance interventions on weight gain was mixed across the short- and long-term and the evidence was of low- to very low-certainty.60  

One study found that dieting, specifically an intermittent very low-calorie diet which includes free meal replacements and intensive dietician support, reduced weight gain at the end of treatment and increased abstinence at 12-month follow-up, compared to education on how to avoid weight gain. However, another study of very low-calorie diets for preventing weight gain during smoking cessation found no participants completed the intervention.60 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.63    

Advice to attenuate weight gain typically includes engaging in physical activity, having a healthy diet and limiting alcohol consumption.64-70 However, such advice does not appear to reduce weight gain and may even reduce abstinence from smoking.71 Nutritional counselling and physical activity counselling may be more promising. A study incorporating both forms of counselling as part of a smoking cessation invention found they were associated with less sugary drink consumption and higher physical activity, respectively.72 A NZ study also found that adding an exercise-counselling intervention to Quitline was associated with increased physical activity. However, the program was only cost-effective in reducing smoking abstinence among participants who adhered to seven or more intervention calls, as such this type of intervention may be best targeted to those who are willing to commit to an intensive intervention.73

A study found that greater trait mindfulness appeared to weaken the link between smoking-related weight concerns and smoking behaviour among young women.74 Further research is needed to explore the effectiveness of mindfulness-based interventions for addressing weight gain concerns in smoking cessation. Mindfulness interventions for smoking relapse generally are discussed in Section

Intensive smoking cessation interventions that combine pharmacological and behavioural strategies to prevent weight-gain may be beneficial. A 2023 trial of an intensive 18-month smoking cessation intervention which included pharmacotherapy, individual and group counselling, weight management counselling and physical activity support for persons with serious mental illness found the intervention was associated with increased abstinence without weight gain compared to standard care.75

Relevant news and research

For recent news items and research on this topic, click  here. (Last updated November 2023)



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