AJPH -- eLetters for Lee and Kahende, 97 (8) 1503-1509

A recent article by Lee and Kathende¹ identified predictors of successful smoking cessation to assist practitioners in tailoring programs for clients at high risk of relapse. These researchers found that cessation was significantly associated with the following factors: having rules against smoking in the home and a tobacco-free workplace; being at least age 35, married or living with a partner, and of non-Hispanic White race/ethnicity; and having only 1 lifetime quit attempt and not having switched to low tar or low nicotine products. Research conducted by FirstHealth of the Carolinas (FirstHealth), a not-for-profit health care system based in Pinehurst, North Carolina,²^-5 both supports these findings and identified other factors to consider toward preventing smoking relapse.

FirstQuit is our comprehensive, evidence-based cessation program that provides individual and group counseling to clients who smoke and are referred for treatment from provider offices in our rural, tobacco-growing service region. Program data corroborate the role of stress and addiction in hindering the cessation efforts of clients (Table 1).

Stress continues to play a large role in smoking relapse over time, as close to 50% or more of smokers identify stress as the reason for relapse up to 1 year post-cessation (Table 1). This suggests the utility of incorporating on-going stress-management components into tobacco cessation programs. Addiction as indicated by physical urges/withdrawals influences relapse most particularly during the first three months after the initial quit date (Table 1). As expected, there is a decrease in reported symptoms of withdrawal over time.

Based upon these findings, FirstQuit has tailored its program to address stress and addiction by adding a component to educate clients about the symptoms of nicotine withdrawal, the reasons for their occurrence, and specific coping strategies. Clients are reminded that withdrawal symptoms are temporary and a sign that the body is healing itself. Ensuring access to nicotine replacement therapies and cessation medications to overcome physical addiction is now focused on the time period closest to the quit date and continued based upon each client’s needs.

On the other hand, stress is addressed continually throughout follow-up. Clients receive a stress management guide and relaxation CD, are invited to attend ongoing weekly support groups, obtain a trial membership to a fitness center, and are connected to additional local resources for mental health assistance, as indicated. Enhancing cessation interventions with timely, tailored resources that address stress and addiction may enhance efforts to prevent relapse in the Carolinas and elsewhere.

Haijun Xiao, MS

Christopher D. Hoffman, MS

Guillermo Brito, PhD

Cindy L. Laton, BA

Sallie Beth Johnson, MPH, CHES

About the Authors

H. Xiao and G. Brito are part of the Research and Evaluation team at the American Legacy Foundation, Washington, DC. C. D. Hoffman, C. L. Laton, and S. B. Johnson are with FirstHealth of the Carolinas, Inc, Pinehurst, NC.

Requests for reprints should be sent to Haijun Xiao, MS, American Legacy Foundation, 2030 M Street, NW, 6th Floor, Washington, DC 20036 (e-mail: jxiao@americanlegacy.org).

Acknowledgments

This study was supported by the American Legacy Foundation/Community Voices initiative and FirstHealth of the Carolinas, Inc. We thank Donna Vallone, Jennifer Duke, and Mary Northridge for their guidance and insightful comments on previous drafts.

References

1. Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007;97:1503-1509.

2. Hartsock LG, Hall MB, Connor AM. Informing the policy agenda: the Community Voices experience on dental health for children in North Carolina's rural communities. J Health Care Poor Underserved. 2006;17(1 Suppl):111-123.

3. Leopper R. Integrating health care into the one-stop system for workforce development as a safety net for ex-offenders. Am J Public Health. 2006; 96:1147.

4. Formicola AJ, Ro M, Marshall S, Derksen D, Powell W, Hartsock L, Treadwell HM. Strengthening the oral health safety net: delivery models that improve access to oral health care for uninsured and underserved populations. Am J Public Health. 2004;94:702-704.

5. Community Voices:Health Care for the Underserved. FirstHealth Community Voices. Available at:

http://www.communityvoices.org/Community.aspx?ID=12. Accessed September 26, 2007.

Table 1-The percentage of clients who self-report being tobacco free and factors that prevented them from staying tobacco free among 418 clients who were smokers and were referred for treatment from provider offices in Moore County and Montgomery County, North Carolina (2001-2003)

	1 month follow up (n=380)	3 month follow up (n=371)	6 month follow up (n=325)	12 month follow up (n=123)
Are you currently tobacco free?
Yes	32.1%	24.8%	20.0%	17.9%
If you are currently tobacco free, have you been tobacco free for the past 30 consecutive days?
Yes	80.3%	45.7%	10.8%	22.7%
If you are currently tobacco free, have you had any relapse since your initial quit date?
Yes	31.8%	28.9%	37.5%	36.8%
What prevented you from staying tobacco free?
Stress^a	43.5%	56.3%	54.9%	67.2%
Physical Urges / Withdrawals^b	30.1%	21.3%	14.3%	3.3%
Around Other Smokers	7.0%	9.1%	12.0%	11.5%
Nervousness	4.3%	4.1%	5.1%	4.9%
Weight Gain	1.6%	2.5%	2.3%	0.0%
Other	14.0%	7.1%	11.4%	13.1%

a. The p-value of the time trend test is 0.003

b. The p-value of the time trend test is 0.000