48 96
incentives
to
encourage
a desired behavior
such
as
smoking
abstinence.
Importantly,
an escalating CM design
is
required
to
be
effective,
that
is,
the
incentive
value must
increase
with
every
demonstration
of
the
desired
behavior
to
avoid
habituation.
CM
for
pregnant
women
increases
smoking
cessation
rates
significantly
compared
with
other
psychosocial
interventions
[18].
In
addition,
CM
interventions
have
a
positive
impact
on
fetal
growth,
birth
weight,
and
breastfeeding
duration
[19].
CM
effects
also
have
demon-
strated
improved
smoking
cessation
outcomes
in
the
postpartum
period:
At
12
wk
postpartum,
24%
of
the
women using CM were
still
abstinent
compared with 3% of
women without
the
intervention
[20].
Motivational
interviewing
is
delivered
in
person
or
by
phone
in
one
to
four
sessions
of
15–45 min
and has
shown
modest
effects
for
smoking
cessation
[21].
Efficacy
of
motivational
interviewing
can
be
improved when multiple
sessions
are
provided
by
primary
care
physicians
or
counselors, with
a minimum duration
of 20 min
[21].
Group
therapy has
shown
superior
efficiency
in
increas-
ing
the
rate
of
smoking
cessation
compared with
self-help
programs
but
not with
individual
counseling
[22].
3.
Implementation
of
smoking
cessation
Among
those
smokers
who
do
not
quit
on
their
own,
successful
cessation
is
dependent
on
interventions
that
consider
the whole
spectrum of
factors
influencing
smoking
behavior
and
nicotine
dependence.
Any
pharmacologic
intervention has
to be delivered within an addiction
therapy
setting because medication alone most
likely will not
lead
to
successful
long-term
cessation.
Many persons with
SUDs
are
addicted
to more
than one
substance,
and
this
complicates
recovery.
In
addition,
successful
smoking
cessation often
leads
to other
‘‘reward-
ing
behaviors,’’
most
prominently,
increased
food
con-
sumption
[23].
In
fact, a
significant portion of
smokers who
quit
smoking
gain
weight
or
even
develop
an
eating
disorder.
This
phenomenon merits
treatment
intervention
because
it puts
former
smokers at
increased
risk
for obesity
[24].
Intensive
lifestyle
interventions have shown efficacy
in
reducing obesity and other cardiovascular and diabetes
risk
factors
and
should
be
considered
from
a
sociopolitical
perspective
for
smoking
cessation
[25,26].
Another
important
aspect
to
consider
is
that
many
persons
with
psychiatric
disorders
smoke
more
heavily,
are more
prone
to
TUD,
and
show
lower
quit
rates
than
those without
such disorders
[5,27–29] .Lifetime
smoking
rates of up to 83% are reported
for thosewith a
lifetime DSM
axis
I disorder
compared with 39%
for
those without
such
disorders
[29] .Nicotine
consumption might
represent
a
form
of
self-medication
for
persons
with
psychiatric
comorbidities
[30].
Furthermore,
the
type
of medication
administered
influences
the
extent
of
self-medication
with
nicotine;
for
example,
atypical
antipsychotics
are
associated with
reduced
severity
of
nicotine
dependence
and
craving
for
cigarettes
compared
with
typical
anti-
psychotics
[31] .A
comprehensive,
structured
diagnostic
process
and
treatment
for TUD
and
for
any
comorbid disorder
is
crucial
as
early
as
possible
because
poor
prognosis
is
expected
if
treatment
fails
to
address
both.
4.
How
to
troubleshoot
problems
in
the
cessation
process
TUD
and nicotine dependence
are
acknowledged
as psychi-
atric
disorders
in
the
DSM
and
the
International
Classifi-
cation
of
Diseases,
respectively,
and
thus
should
be
included
as
integral
parts
of
the
diagnostic
process
and
in
medical
reports,
including
the
number
of
cigarettes
smoked per day and
treatment
suggestions. This approach
has
the potential
to
call patients’
attention
to
the
severity
of
the disorder, especially among
those who are not willing
to
make
a
quit
attempt,
and
to
raise
awareness
among
general
practitioners.
Intrinsic
motivation
is
a
key
variable
in
the
smoking
cessation
process.
This
is
highlighted
by
smoking
cessation
during pregnancy.
Increased
intrinsic motivation
to deliver a
healthy baby
is seen as an
important window of opportunity
for quitting smoking
[32]. Up
to 45% of smoking women quit
without assistance between
learning of
their pregnancy and
their first prenatal visit
[18] ;however, up to 80% relapse after
the postpartum period
[33].
If
intrinsic motivation decreases
(eg, after delivery or after
the breastfeeding period), prompt
professional support with effective
interventions such as CM
is
crucial
to
avoid
relapse.
Smoking
cessation
typically
follows
a
cyclical
pattern:
The
average
smoker makes
at
least
four quit
attempts until
achieving successful
long-termsmoking cessation
[34] .Con-
sequently,
support
has
to
be
offered
repeatedly
because
every
quit
attempt
increases
the
chances
of
ultimate
successful
cessation
[35].
5.
Conclusions
Smoking
behavior
is
a
complex
phenomenon
that
entails
innumerable
variables.
Key
factors
such
as
psychiatric
comorbidity
play
significant
roles
in
smoking
prevalence
and
in
failed
cessation
and
relapse.
Successful
treatment
interventions must be based on
a
comprehensive diagnosis
and must
consider
the whole
spectrum
of
factors
influenc-
ing
smoking
behavior
and
nicotine
dependence.
From
a
public
health
perspective,
broader
availability
and accessibility of
treatment options—especially
increased
quality
of
smoking
cessation
interventions—has
the poten-
tial
to
increase
patients’
health
and
quality
of
life
and
to
significantly
lower
the
considerable
societal
and
economic
burden
caused
by
smoking
[15,36].
Author
contributions:
Laura Brandt had
full
access
to
all
the data
in
the
study
and
takes
responsibility
for
the
integrity
of
the
data
and
the
accuracy
of
the
data
analysis.
Study
concept
and
design:
Fischer,
Brandt.
Acquisition
of
data:
None.
Analysis
and
interpretation
of
data:
None.
Drafting
of
the manuscript:
Brandt.
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U R O L O G Y
F O C U S
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