PALO ALTO CENTER FOR PULMONARY DISEASE PREVENTION
Checklist Developed by & Information Prepared by:
David P.L. Sachs, MD
Director, Palo Alto Center for Pulmonary Disease Prevention
Palo Alto, CA
- Similar to the Pre-Treatment Checklist, Dr. Sachs realized about 6 years ago that there were a number of topics he wanted to make certain that he covered with each patient at some point after their Target Stop Date. He determines the precise timing of when to bring up the Relapse Prevention strategies based on each particular patient. He has never brought up these strategies before one month after Target Stop Date.
- Running down this simple list, the patient needs to understand that craving for cigarettes is, physiologically, going to intensify around day 10–13, increasing by about 25% from where it had been before. Simply knowing that fact may be reassuring to the patient. Other patients may need to temporarily increase their pharmacotherapy. Also, the patient needs to understand that craving intensity can last anywhere from months to years, as has been shown in the published literature. The patient needs to know that approximately 75% of relapse occurs in a high-stress situation, particularly where the patient is using a modest amount of alcohol. Approximately 25% of relapse occurs in a celebratory setting, also while using modest alcohol. The important point is that if the patient knows these facts and plans for them, then the patient will be much less likely to relapse.
- The “Strategize/’Program ROM’“ simply refers to a strategy that Dr. Sachs’s patients have told him they have found extraordinarily useful. This exercise means imagining the most stressful situation the patient could possibly experience. For most of us, this would be the unexpected loss of a spouse, child, or loved one. Then the patient needs to think through very specific, concrete steps that the patient would take in that setting to deal with that unexpected major life stress, without using a cigarette. An example that Dr. Sachs uses in clinical practice is he tells the patient that he gets a telephone call from the highway patrol advising him that his wife has been in a serious car wreck and they are trying to extract her with the “jaws of life” and have not even yet been able to determine if she is still alive.
- The line “Wallet Card” refers to another simple trick patients told Dr. Sachs that they have used and came up with on their own. He has passed that on to other patients, who have likewise found it helpful. What this means, simply, is taking a wallet-sized business card, on which the patient writes his or her Target Stop Date and the top three reasons why the patient wanted to stop on that date. Then put that card in the wallet, which is always with the patient. Then when the patient gets an urge to smoke a cigarette, Dr. Sachs reminds the patient to pull the card out of the wallet, re-read it, and determine whether those reasons still apply, before even going after a cigarette. Most patients report that they never even need to pull the card out of their wallet; they remember quite vividly what they wrote on that card, even though many years might have elapsed.
- The lines that state “Think Something Different” and “Do Something Different” refer to pioneering work initially done by Saul Shiffman in 1984 and confirmed by many other authors. These articles are cited in the body of the Tool Kit. Basically, what these investigators found is that if a person both thinks and does something different when experiencing a desire for a cigarette, after having stopped smoking, that that will abort the urge for a cigarette. The “Thinking Something Different” can be as simple as asking oneself the question “What do I want to have for dinner tonight?” The “Doing Something Different” can be as simple as turning in one’s chair and looking out the door or out the window.
- The line headed Pharmacological Interventions is simply to remind the patient that nicotine Rescue Medications, in particular, can be extraordinarily effective in helping deal with transient, infrequent occurring settings or situations that might lead to relapse. The subsequent three lines also indicate that it is perfectly acceptable to restart a medication that has been stopped, when the need arises.
- The last line in the Relapse Prevention Checklist serves as a touchstone for Dr. Sachs to remind the patient that usually somewhere between 6–10 days occur between the first actual lapse – the first time of having one puff or even a whole cigarette – and then actual relapse back to regular, daily smoking. Thus, this time interval is a crucial interval of opportunity for the patient to telephone the treating physician, and come in to discuss with the physician what appropriate strategies might be to help prevent that lapse from deteriorating into full relapse.
How to Use the Relapse Prevention Checklist
- Check the “Y” column when you have fully covered the topic, consistent with the patient’s needs.
- Check the “±” column when you have partially covered the topic but have elected to defer completing the discussion to a later or better time (e.g., when the patient will be better able to actually hear the information and process it).
- Check the “N” column when you have decided that you do not need to cover the topic with that patient.