CHAPTER 9. TOBACCO USE 245 avoiding"rewarding"themselves for not smoking with rich foods or special meals(see Chapters 7 and 8). Recommendations for more frequent physical activity (even in short bouts)may both help prevent weight gain and support smoke-free behavior(see Chapter 6) Multiple relapses Many smokers, especially adults older than 40 years, have made several serious attempts to stop smoking but have always relapsed. Nicotine is a powerfully addictive drug. These patients have frequently tried various smoking cessation products and programs, all without success. Such patients are often discouraged by their failed attempts to stop and are therefore less willing to try again These patients(and their clinicians)need to be aware that relapse is a typical part of the cessation process. Most smokers require several attempts to achieve permanent abstinence, and knowing this may bring encouragement to relapsing smokers. Even in a relatively short clinic visit, a clinician can help a patient benefit from past relapses rather than view them as a personal failure and a reason to avoid future quit attempts. During the visit, the clinician can help the patient to identify the circumstances that led to past relapses and to develop strategies for use in either avoiding those circumstances or responding to them in a different manner. A simple question from the clinician--such as "When you resumed smoking, where did your first cigarette come from?or what was going on in your life when you started up again?"will start the discussion of the reason(s) for relapse. There are several common reasons offered for relapse including withdrawal symptoms, weight gain, stress"at work or home, alcohol intoxication, or social pressure. Once the patient has described the circumstances of the relapse, the clinician can ask, How do you think you would deal with that situation if it happened again?"or"How do you think you could avoid that situation in the future?"The clinician can offer advice about some situations and help with withdrawal symptoms(see Table 9.3), but the patient must develop a personalized plan for responding to circumstances Patients commonly say that they had a relapse due to stress at their job or at home. Marital difficulties, problems with other family members, loss of a job, or increased work responsibilities are often given as reasons for relapse Patients, with the help of their clinician, need to anticipate the difficult times that may occur while they are attempting to quit and be prepared with a response other than taking up smoking again. Simple responses to craving, such as chewing gum, taking a walk, or engaging in relaxation exercises, may be all that a patient needs to cope with a difficult personal situation. In all cases, having a concrete plan in place to address these stressful situations is critical