Withdrawal Orientated Approach

Cessation treatment based on controlling withdrawal symptoms assumes that individuals attempting to stop nicotine use are dependent on nicotine, and that the discomfort of withdrawal is a major issue in successful cessation.

Withdrawal orientated approach to cessation can be seen as an adjunct to other methods of smoking cessation, particularly when issues arise in self-efficacy and quitters become tempted to relapse.

As an example, an individual who is in the maintenance stage of change may be tempted to smoke due to their social situation and recent cessation. Withdrawal orientated approach utilises nicotine replacement and behaviour management to control these urges.

The use of group behavioural therapy in the withdrawal orientated approach is discussed by Hajek (1989), and focusses on the following:

A Group Structure

used because it allows individuals in similar situations to get to know each other, interact and discuss their personal experiences within a relevant forum. This also removes the focus from the cessation therapist to other members of the group, which removes any aspect of didacticism from the intervention. This shift in focus has been shown to reduce drop out from behavioural management in individuals attempting to quit (Hajek 1985).

Running the intervention over 4 weeks

means that individuals receive the treatment they require during the acute withdrawal period (West 1987). Whilst some individuals would appreciate a longer course, this is not associated with any increase in successful cessation.

Education of Withdrawal Symptoms

this ensures individuals know what to aspect during their cessation attempt, and that what they are experiencing is normal (West 1986). By normalising and discussing these symptoms, the intention is to influence those with more severe withdrawal symptoms (who are in turn are more likely to relapse) that their withdrawal is, in fact, manageable (West 1989).


Carefully Selected Group Size

12-15 members has been shown to be the optimum number (Hajek 1986). In this size group, there are sufficient numbers to create a ‘bandwagon,’ effect and boost morale, whilst being unaffected by a small number of dropouts. In a smaller group, dropouts are more noticeable and a larger group may impede on individual involvement and creation of interpersonal ties within the group.

Limited Educational Material Disseminated

Individuals who have reached this stage are assumed to have a certain amount of cessation knowledge. By focussing brief education towards the end of the group of sessions it simply gives the individuals an educational boost, when novelty and drive to remain abstinent may be beginning to wane.

Limited availability of re-entry

It has been shown that if individuals are told they can only enrol on such a scheme once a year they are more likely to be more determined to use the opportunity available to them and prevents populating the groups with individuals who repeatedly fail, which may result in unbalancing the group dynamic. 

Withdrawal Symptoms

As healthcare practitioners, it is also important we understand and can identify withdrawal symptoms. These symptoms are strongest in the first few days, and dissipate over 4 weeks (Hughes 2007), which is concurrent with the length of time the withdrawal orientated approach is used. The most common withdrawal symptoms are (Hughes 1991):

  • Restlessness
  • Anxiety
  • Difficulty concentrating
  • Irritability/Anger
  • Sleep disturbance
  • Hunger or weight gain

These symptoms can be remembered through the mnemonic RADISH.

‘Not a Puff’ rule

When assisting with a quit attempt it is important to stress likely difficulties, for example dealing with withdrawal symptoms. However, one of the most important things to stress to individuals who have recently quit or are going to quit is the ‘not a puff’ rule.

If an individual breaks a self-imposed rule, even once, there is a tendency to abandon the behavioural aim. A significant number of quitters will smoke in the first few days of quitting.

Those that lapse once are very unlikely to recover and remain abstinent.

There is a strong link between alcohol consumption and lapse in cessation, meaning cessation advice for individuals should include advice regarding the avoidance of alcohol consumption.

Bibliography and Further Reading
Anderson CM, Zhu SH. Tobacco quitlines: looking back and looking ahead. Tobacco Control 2007;16 Suppl 1:i81–86.
Brandon TH, Collins BN, Juliano LM, Lazev AB. Preventing relapse among former smokers: A comparison of minimal interventions through telephone and mail. Journal of Consulting and Clinical Psychology 2000;68:103–13.
Brown RA, Lejuez CW, Kahler CW, Strong DR, Zvolensky MJ. Distress tolerance and early smoking lapse. Clinical psychology review. 2005 Sep 30;25(6):713-33.
Brunette MF, Ferron JC, Gottlieb J, Devitt T, Rotondi A. Development and usability testing of a web-based smoking cessation treatment for smokers with schizophrenia. Internet Interventions. 2016 May 31;4:113-9.
Chauhan P, Dev A, Desai S, Andhale V. Nicotine replacement therapy for smoking cessation. Pharmaceutical and Biological Evaluations. 2016 Jun 11;3(3):305-12.
Hajek P, Belcher M, Stapleton J. Enhancing the impact of groups: an evaluation of two group formats for smokers. British Journal of Clinical Psychology. 1985 Nov 1;24(4):289-94.
Hajek P. Nicotine chewing gum in the group treatment of smokers. InWorld Congress, Harvard University, Cambridge, Institute for the Study of Smoking Behaviour and Policy 1986.
Hajek P. Treatments for smokers. Addiction. 1994 Nov 1;89(11):1543-9.
Hajek P. Withdrawal‐oriented therapy for smokers. British journal of addiction. 1989 Jun 1;84(6):591-8.
Hall SM, Humfleet GL, Reus VI, Munoz RF, Cullen J. Extended nortipyline and psychological treatment for cigarette smoking. Am J Psychiatry. 2004;161(11):2100–2107.
Hughes JR, Gust SW, Skoog K, Keenan RM, Fenwick JW. Symptoms of tobacco withdrawal: a replication and extension. Archives of general psychiatry. 1991 Jan 1;48(1):52-9.
Hughes JR. Effects of abstinence from tobacco: etiology, animal models, epidemiology, and significance: a subjective review. Nicotine & Tobacco Research. 2007 Mar 1;9(3):329-39.
Lai DTC, Cahill K, Qin Y. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2010;1:CD006936.
Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. The Cochrane Library. 2005 Jan 1.
McKee SA, Krishnan-Sarin S, Shi J, Mase T, O’Malley SS. Modeling the effect of alcohol on smoking lapse behavior. Psychopharmacology. 2006 Dec 1;189(2):201-10.
Pommerenke FA, Dietrich A: Improving and maintaining preventive services, Part 2: Practical principles for primary care. J Fam Pract. 1992, 34: 92-97.
Rigotti NA, Rennard SI, Daughton DM. Benefits and risks of smoking cessation. UpToDate. Waltham (MA): UpToDate; Available at: http://www. uptodate. com/contents/benefits-and-risks-of-smoking-cessation. 2013:1-50.
Roberts NJ, Kerr SM, Smith SM. Behavioral interventions associated with smoking cessation in the treatment of tobacco use. Health Services Insights. 2013;6:79.
Russell MA, Jarvis MJ. Theoretical background and clinical use of nicotine chewing gum. NIDA research monograph. 1984 Dec;53:110-30.
Schwarzer R. Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology. 2008 Jan 1;57(1):1-29.
Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. The Cochrane database of systematic reviews. 2001 Dec(3):CD001007-.
Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database Syst Rev. 2005 Apr 18;2(2).
Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. The Cochrane Library. 2006 Jul.
Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. The Cochrane Library. 2006 Jul.
Vangeli E, Stapleton J, West R. Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation. Patient education and counseling. 2010 Nov 30;81(2):267-71.
West RJ, Hajek P, Belcher M. Severity of withdrawal symptoms as a predictor of outcome of an attempt to quit smoking. Psychological medicine. 1989 Nov 1;19(04):981-5.
West RJ, Hajek P, Belcher M. Time course of cigarette withdrawal symptoms during four weeks of treatment with nicotine chewing gum. Addictive behaviors. 1987 Dec 31;12(2):199-203.
West RJ, Hajek P, Belcher M. Which smokers report most relief from craving when using nicotine chewing gum?. Psychopharmacology. 1986 Jun 1;89(2):189-91.
Wu L, He Y, Jiang B, Zuo F, Liu Q, Zhang L, Zhou C. Additional follow-up telephone counselling and initial smoking relapse: a longitudinal, controlled study. BMJ open. 2016 Apr 1;6(4):e010795.
Zhu S, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med. 2002;347:1087–1093.
Nicotine by Pablo Andres. Available at https://www.flickr.com/photos/pabloeivissa/6184106249/in/photolist-aqtakx-pNPvU-4tEZC7-pNPp1-ex51wP-pjVe9a-pNPh9-r48jfp-eDbYd1-aGfaVe-6LynGd-nzPJGo-4FzAy1-73ftv3-cVWMH3-7x3LSy-4mqAj-4xs3eB-9nbQmm-7qKFNn-9abURx-3tTCR-7fF98H-outau-69mU6h-5ojLyi-9af5xE-GJsFs-2bZHo-3YBW2E-a3ZmAm-26qEHN-x1ohv-7Whpjr-7hbTfG-niAYu-AJtiMB-qWsaXB-59dyLh-3eHxN-4wp51L-9a3C5G-6iwBW-au1L5S-3caTjw-bqvuxr-p1n4NV-qfTv4X-qbLe2S-ijBdaF Licensed under CC BY-NC-ND 2.0
Group by Stephen Downes. Available at https://www.flickr.com/photos/stephen_downes/506074326/in/photolist-LHLgq-fTwoz-arcecj-bq2QLM-H1kyS-2meeyh-4A27Tz-G6FoD9-HnuxC-jtiii-fREeL-jthMt-FAwnTX-bq2MLk-jti2M-8PYJjH-FyUo-jtitX-zuEuPM-dbk7U-tdE1m-jNmaQ-9M6uNQ-dABGVR-wKPZuX-7tiRJL-dAHbq9-qf2eoe-27Svp-pZTtRL-h6m1Zn-RCE3kh-fMRhu6-4U9bph-2VDvaD-64ewNJ-fKgDtT-7frcdX-2t8c1-nNN4xY-bJnqoR-4R1ka1-cbpWRC-38uNrj-8EbnMj-m5rFgr-6VucP1-HPM6Gx-4PwbCE-fKgLsc Licensed under CC BY-NC 2.0
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Did you Know

An estimated 2.8 million adults in Great Britain currently use e-cigarettes. Of these,1.4 million continue to smoke and 1.4 million now completely rely on their e-cigarette.