Stopping smoking: a therapist's manual

1. The programme at a glance

Indication. An adult who smokes, who is dependent on tobacco and who is considering stopping, whether already decided or still in two minds. The programme can be adapted for adolescents from the age of fifteen, under the conditions set out in section 29. It is also intended for smokers who have an anxiety disorder, a depressive disorder or another stabilised psychiatric disorder, for whom stopping is often wrongly postponed (sections 8 and 29). A person who does not wish to stop does not enter the programme: they receive the brief intervention of section 3, and the door stays open.

Reference model. The treatment of tobacco dependence has one of the strongest evidence bases in the whole of preventive medicine. Three findings give this manual its structure. Behavioural support, individual or in a group, increases the chances of stopping compared with minimal support (Lancaster and Stead, 2017; Stead, Carroll and Lancaster, 2017). Pharmacological aids — nicotine replacement therapy, varenicline, cytisine, bupropion — and the nicotine electronic cigarette also increase those chances (sections 11 and 12). And the two add up: adding behavioural support to a medication improves the result further (Hartmann-Boyce et al., 2019). The psychologist provides the support; they make sure that a pharmacological aid is discussed with a prescriber, chosen by the person and used correctly.

Format. Nine sessions. The first two, for assessment and decision, take place one week apart; the third prepares the quit attempt and sets the date, within the following one or two weeks. Sessions 4 to 8 take place weekly from the quit date, session 4 within the very first days. Session 9 takes stock, about two months after the date. Three booster sessions follow, at one, three and six months after the quit date, which puts the last one about three and a half months after session 9. Individual sessions last 45 to 60 minutes; in a group of six to twelve people, 60 to 90 minutes (section 28). A brief call, of five to ten minutes, is planned for the day after the quit date. Section 14 justifies this schedule.

Target mechanism. Three changes, in this order: that the person decides to stop on a given date, with a suitable pharmacological aid; that they get through the withdrawal and the urges of the first weeks without smoking, knowing what lies ahead; and that they learn to cope, without a cigarette, with the situations and emotions that used to make them smoke, including after a lapse.

Session	Timing	Focus	Session deliverable
1	Week 1	Assess and take stock	Dependence measured, risks identified, log handed over
2	Week 2	Decide	Written balance, importance and confidence rated
3	Week 2 or 3	Prepare to stop	Date set, aid chosen with the prescriber, written plan
4	Days 2 to 5 after the date	The first days	Abstinence verified, aid adjusted if needed
5	Week 1 after the date	Withdrawal and urges	Urge method practised in session
6	Week 2 after the date	Situations and emotions	Plan for each situation, emotions without a cigarette
7	Week 3 after the date	Lapse and relapse	Written course of action in case of a lapse
8	Week 4 or 5 after the date	The body: weight, sleep, movement	Plan for the body, alcohol reviewed
9	About 8 weeks after the date	Maintain	Measures repeated, written plan for what comes next

What the person takes away. Nine printable worksheets, listed in section 34: my cigarette log, my balance and my reasons, my quit plan, my urges, my high-risk situations, if I smoke a cigarette, my body while stopping, the corner for those close, my plan for what comes next. The site's guide for the general public, Stopping smoking, can be recommended as a complement: it covers, in plain language, most of the information in the sessions, and it names no medication and no dose.

What sets this programme apart from the other manuals on this site. Its main outcome is binary and verifiable: the person smokes or does not smoke, and exhaled carbon monoxide confirms it. And medication is not one option among others here, but an expected partner of psychological support.

2. Before you begin

The four preliminary decisions

Does the person want to stop? This is the first question, and it is asked at session 1. Many smokers are in two minds: they want to stop and they do not. Ambivalence is not an obstacle to the programme; it is its starting point (session 2). But a person who does not want to stop, or who comes only because someone pushed them, does not start a quit programme: they receive a brief intervention, and the offer remains open (section 3).

Is a pharmacological aid possible? Almost always, yes. The programme asks that every person has talked it over with a prescriber before their quit date, and has made an informed choice, including the choice to do without (section 12).

Is there a situation that changes the approach? Several situations change it: a pregnancy, a psychiatric disorder, treatment with clozapine or olanzapine, another addiction, a planned hospital stay, an age under eighteen. None of them contraindicates stopping; all of them modify the programme (sections 9 and 29).

Is there a risk? A suicide risk, an unstable mood disorder, alcohol use that exposes the person to dangerous withdrawal: these are explicitly looked for at session 1 (section 9).

What this programme does not treat

It does not, on its own, treat another active and severe addiction. An alcohol or cannabis use disorder is treated with its own protocol, Alcohol use disorder: a therapist's manual or Cannabis use disorder: a therapist's manual; stopping smoking can happen at the same time or afterwards, depending on the person (section 29). It must not be postponed indefinitely on the grounds that one should "sort out the rest first".

It does not treat an unstable psychiatric disorder. A severe depressive episode, a manic episode, a psychotic decompensation are treated first; stopping smoking is taken up again once the situation has stabilised, with the precautions of section 29.

How to use it

Read the whole manual before the first session, in particular sections 6, 10, 12 and 14 — the model, the measures, the place of medication and the framework — then sections 25 to 27 before the sessions that draw on them. Each session is described with the same framework: the objective, the step-by-step outline, what you say, what you do not say, common mistakes, and the criterion for moving on.

Three warnings specific to this reason for consultation.

The most likely drift is stopping without any aid. Many smokers want to stop "by willpower", and many therapists, without having decided to, go along with it. It is the least effective strategy: without help, only 3 to 5% of smokers are still abstinent six to twelve months after an attempt (Hughes, Keely and Naud, 2004). Your role is not to impose a treatment, but to make sure the choice is an informed one (section 12).

The mirror-image trap is moralising. The smoker knows the harms of tobacco better than anyone; repeating them increases resistance rather than motivation. Medical information has its place, brief and asked for; the sermon has none (section 25).

And timing matters. Relapses happen early (section 14): the call on the day after and session 4 are not optional.

3. Who to offer the programme to, and when

Three situations

Smokers who consult, or whose smoking comes up in the course of another treatment, find themselves in one of three situations. They do not call for the same approach.

1. The person does not wish to stop now. They smoke, they know it, they did not come for that, or they say clearly that now is not the time. What fits then is a brief intervention of a few minutes: ask whether they smoke and how much, tell them in one sentence that stopping is the most useful change they could make for their health and that effective aids exist, ask them what they think about it, and tell them the door is open. You do not offer them the nine sessions; you do not lecture them; you will come back to the question later. If they are in another therapy with you, tobacco remains a question you will ask again, without insisting.

2. The person is in two minds, or decided. They want to stop, or they hesitate and agree to talk about it. This is the indication for the programme. Hesitation is not a contraindication: session 2 is made for it.

3. The person has recently stopped, alone, and fears starting again. They stopped a few days or a few weeks ago, they are holding on, but the urges are strong or a return to smoking threatens. The programme then begins at session 1, to measure, then moves directly to session 4 or 5 depending on the time elapsed: sessions 2 and 3 are reduced to a quick check of what has been decided and to a discussion of a pharmacological aid, which may still be useful.

What research says about timing

The decision to stop is made more often than people think. Many smokers say they want to stop, and some of them make at least one attempt every year. This means that a large share of the smokers you meet are, at least at times, in the second situation.

The opening question

"Where are you with tobacco, today?" It opens the conversation without presupposing the answer, and it allows the person to say "I want to stop" just as easily as "that's not why I'm here". It is the answer, and not your wish, that decides what comes next.

4. Tobacco dependence: clinical description

What nicotine does

Inhaled in smoke, nicotine reaches the brain within a few seconds. It brings a slight improvement in alertness, concentration and mood, and a feeling of calm. The speed of this link between the gesture and the effect, repeated thousands of times a year, is what makes the cigarette particularly conducive to dependence. Nicotine maintains the dependence; it is not nicotine but the products of combustion — tar, carbon monoxide, particles, carcinogenic substances — that cause most of the diseases. This distinction underpins the place of nicotine replacement therapy and the electronic cigarette (section 12).

The three components of dependence

Pharmacological dependence. Between two cigarettes, the regular smoker is not in a neutral state: withdrawal sets in as time passes. The next cigarette does not lift them above normal; it brings them back to it. This is the origin of the impression that "a cigarette relaxes you": it relieves a discomfort that it created itself.

Behavioural dependence. The gesture is associated with hundreds of situations: coffee, the car, the end of a meal, the phone, a break, waiting, alcohol, friends. Each one becomes a trigger. It is this component that explains the urges that arise months after stopping, when pharmacological withdrawal has gone.

The emotional component. Many smokers use cigarettes to cope with anger, boredom, anxiety or sadness, or to give themselves a break. The cigarette fulfils a function; stopping it without finding another way of fulfilling that function leaves the person exposed to starting again (session 6).

Withdrawal

Stopping smoking causes a predictable withdrawal syndrome. In a review of symptoms whose validity is established, anger or irritability, anxiety, depressed mood, difficulty concentrating, impatience, insomnia and restlessness peak in the first week and last two to four weeks; constipation, cough, dizziness, more vivid dreams and mouth ulcers can also be part of it (Hughes, 2007). Appetite increases, and this increase lasts longer. Knowing that these symptoms are expected, that they have a peak and an end, changes the way the person experiences them: the third day is not proof of failure, it is the expected time of the peak.

Craving

Craving — the imperious desire to smoke, which we will simply call the urge here — is not a continuous state. It comes in waves, triggered by a situation, an emotion, a smell or withdrawal; it rises, peaks and subsides within a few minutes if the person does not smoke. Two forms coexist: the background urge, linked to withdrawal, which pharmacological aid greatly reduces, and the triggered urge, linked to situations, which persists longer and is worked on through behaviour (section 26).

The markers of strong dependence

Two simple indicators predict how hard stopping will be and guide the choice of pharmacological aid: the time between waking and the first cigarette, and the number of cigarettes per day. Together they form the Heaviness of Smoking Index, presented in section 10 (Heatherton et al., 1989). To these are added smoking at night, smoking when ill in bed, and difficult withdrawal during previous attempts.

5. What keeps smoking going

The reinforcement of relieved withdrawal

Each cigarette relieves the withdrawal that has built up since the previous one. This relief is a powerful reinforcement, immediate, repeated twenty times a day. It gives the cigarette a value that the person attributes to the cigarette itself — "it relaxes me" — whereas it mostly comes from the end of withdrawal.

Associations

Coffee, the car, the end of a meal, a break, the phone, alcohol become, through thousands of repetitions, signals that trigger the urge. These associations long outlive pharmacological dependence. That is why stopping is prepared situation by situation (sessions 3 and 6).

The emotional function

When the cigarette is the main way of coping with anger, boredom or anxiety, stopping it leaves a gap, and every strong emotion becomes an occasion for starting again. The work consists in replacing the function, not just the gesture (session 6).

The abstinence violation effect

After a lapse, a person who attributes it to their own personal weakness, who feels guilty and who loses confidence in their ability to hold on, is more likely to move on to a full relapse. Marlatt and Gordon called this phenomenon the abstinence violation effect; among smokers who had stopped, reactions of this kind after a first lapse predicted progression to relapse (Shiffman et al., 1996). That is why the lapse is prepared for before it happens (session 7).

The full circle

Withdrawal or a situation triggers the urge. A thought gives permission for the cigarette. The cigarette brings relief, and this relief strengthens the link. After stopping, a lapse followed by guilt and discouragement leads back to smoking, and the person concludes that they will never manage it. This is the diagram you draw with them at session 2.

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