INTRODUCTION: THE USE OF SNUFF AND HEALTH
the damages that smoking on the health aspects are better known and is, in developed countries, the first problem likely public health prevention.
snuff consumption damages the respiratory system contributes to the onset of cardiovascular problems and has been associated with the presence of some cancers may be said, therefore, that smoking reduces life expectancy.
There are more than 400 substances in cigarette smoke, including some pharmacologically active antigenic, cytotoxic, mutagenic and carcinogenic.
The snuff is a cardiovascular risk factor of first order, increasing the occurrence of arteriosclerosis and morbidity and mortality from coronary heart disease, peripheral arterial disease and cerebrovascular disease. During pregnancy has negative effects on the health of pregnant women and endangers the health of your child.
The mortality attributable to consumption of snuff has risen, yet the problem remains more or less chronic, favored among others by economic and business benefits.
data on the consumption of snuff in Spain indicate that 36 100 people over age 15 are consumers of snuff, and the distribution by sex shows that are smokers to 51.5 per 100 for males and 21, 4 per 100 women.
DETERMINANTS OF SMOKING BEHAVIOR
The acquisition of the smoking habit is the result of a complex process of ontogenetic development. The evolutionary history of smoking appears to produce step by step through a series of steps that have unique characteristics.
Factors affecting learning of smoking
Explain why people start smoking is a key issue for the design of preventive activities. Lichtenstein (1982) mentioned how the social endorsement, curiosity, the role of defiance, the anticipation of the role of adult social pressure, the modeling of parents and peers and advertising are the factors in the natural history of behavior smoking, explain the onset smoking.
Peer pressure is probably one of the first movers to experimentation with snuff, and are partners, peers, who exert the pressure that would lead to try a cigarette
Another factor to consider is the drug aspect. Nicotine is an alkaloid that is classified as a drug and produce some reactions that smokers perceive as beneficial, weight regulation, regulation of mood and cognitive performance improvement, addictive and acts as a reinforcer of behavior. Is capable of producing dependence, which can be inferred from the introduction of the withdrawal, due to the lack of drugs, and tolerance, which manifests itself in the need to increase the doses for the desired effects.
Thus, once the consumption, physiological determinants, effects of nicotine, they start to play an important role in the automation of smoking behavior
Knowing why individuals begin smoking can design preventive action, but not find the hints on how to act so that people will abandon the habit is already established.
economic and social determinants in the habit of smoking
Within the group of environmental factors include the socioeconomic aspects surrounding the product, and availability, as well as social permissiveness.
The influence of advertising, its capacity as a stimulus to the response to smoke, and the cognitive effect is present snuff consumption while ignoring the harmful consequences associated with smoking
physiological and psychological determinants in maintaining smoking behavior
Overall, the effects of nicotine as an addictive substance, and the immediate consequences of consumption (pleasure on the one hand and the completion of the withdrawal symptoms and other) performance enhancers.
Smokers of low nicotine cigarettes do not consume less nicotine than smoking other cigarettes, but simply smoke more.
People who stop smoking continue, often feeling the desire to use snuff (craving), and often fall in consumption after a long time since that nicotine was no longer present in your body. Therefore, it needs to resort to these factors both biological and other psychological and social
Can I smoke in a wide variety of situations and while doing almost any other activity. The many contexts in which smoking go on to become discriminative stimuli for smoking behavior, in whose presence the behavior occurs and is rewarding.
Also, there have been studies concluding that people smoke as a coping strategy against stress. Therefore
thousands of repetitions of behavior, more than 50,000 a year for a person who smokes 20 cigarettes a day (Sarafin, 1990), in all situations, determine the broad generalization of this behavior, which is to be set up as a well established and persistent habit.
ASSESSMENT OF SMOKING BEHAVIOR
Interview with smoking
The smokers' behavioral interview aims to collect information relevant to the description of the circumstances in which smoking behavior occurs, for the development of hypotheses about antecedent and consequent conditions maintaining the habit and knowledge of resources and coping skills of clients.
Structured interviews for the evaluation of smokers often gather information concerning: a) social and family context of the client; b) the circumstances that led to the establishment of the habit and to those of previous quit attempts; c) the topographical aspects of smoking behavior, d) the current reasons for exposing himself to a treatment program, and e) to expectations for this treatment. Also some motivational aspects, such as discomfort caused by the use of cigarettes or expectations of the benefits go to treatment, are in the interview a suitable framework for evaluation.
appropriate that the information obtained through the interviews are contrasted with more interviews with the subject, interviews with their relatives and / or other information gathering techniques. Using
self-reports constitute the most used in this context.
addition to the frequency of the motor response of smoking, self-registration may include observation of other categories of response and situational conditions consistent background or behavior, in practice, you should not include more than six categories, being a good start with the simple strategy observing the occurrence of behavior, and include then, progressively, all other categories of interest.
Among the most common systems used was the notation on a role of the observed variables, but also offered to smokers have different mechanical and electronic devices. When using paper and pencil procedures should employ a self-registration form that provides a comfortable and easy use by smokers.
A particularly important aspect is the reactive effects produced by self-observation on smoking behavior. This may adversely affect the accuracy of the data. Basically, reactive effects of self-reports tend to include, with large differences between individuals, increased motivation for treatment, but could constitute a limitation of self-registering as a measure favors a positive response to the intervention.
Questionnaires and scales to evaluaci6n of smokers
Two objectives:
- diagnostic classification of subjects, and assessment
- variables considered as predictors of treatment efficacy. Such measures its utility based on the possibility of interindividual comparisons.
Within the same approach that seeks the classification of smokers, but from different theoretical perspectives have been developed other questionnaires and scales as the motivation questionnaire smoking (Tomkins, 1966) and the scale of pros and "cons" of smoking (DiClemente).
As predictors of success in the treatment of smokers, have been used for the past decade self-efficacy scales, from which to highlight the scale of trust in situations smoking (Condiotte and Lichtenstein, 1981).
Other questionnaires to measure personality variables have also been used relatively often, to evaluate the characteristics of smokers in this sense, the dimension of Locus of Control (LOC), presenting, in general, subjects more internal, more likely to remain abstinent than external subjects. Physiological measures
The priority objective confirmation of abstinence and / or a finding that will produce a decrease in the frequency of smoking.
Thiocyanate is a good measure of smoking, the average life of this product in biological fluids is between 10 and 14 days and slowly eliminated, mainly through the urine.
Cotinine, with a half life in the body about 20 hours to be observed in blood or plasma, which due to the invasiveness of the procedures to be very useful, now attempts are underway to assess cotinine in saliva, what is expected in the near future to increase its use.
nicotine assessment was carried out taking into account their presence in blood, saliva and urine, using sophisticated laboratory procedures. These circumstances, together with its short life, have resulted in a measure has not been much used in smoking cessation programs.
Evaluation carbon monoxide (CO) in exhaled air, which is a simple and noninvasive estimation of carboxyhemoglobin (COHb), besides being cheap and not require specialized personnel, the criterion used for the estimation of smoking behavior present 5 to 10 parts per million of carbon monoxide.
TREATMENT OF SMOKING
types of interventions for smoking cessation
They fall into four main sections: social interventions, procedures, self-help interventions in community and / or labor and clinical interventions.
Interventions social / institutional and self-help procedures
social interventions are characterized mainly by:
- be directed to collective
- the use of social media and
- assume that the repeated calls to abandon of snuff will mean that the subjects change their attitudes and stop smoking. It is considered that the information on the harmful aspects of the use of snuff can motivate smokers to change their habit, but does not take into account the possibility of offering concrete help ..
self-help manuals are the most attention has been given to date, typically include information about the risks of smoking and the benefits of its abandonment, as well as concrete suggestions on how to quit.
The advantages of this procedure
- The cost-effectiveness: cost;
- The accessibility of the therapeutic device, and
- seems that self-help procedures favor the maintenance of the achievements producing a lower relapse rate.
as classic material, we can mention the manual Break the Smoking Habit (Pomerleau, 1977), recently published in Spain under the entitled "How to Quit Smoking: an invaluable aid to permanently delete cigarettes in an easy and safe" (Pomerleau, 1992).
reported abstinence rates are highly variable between 0 and 74 100.
seems likely that, due to its easy application and distribution, the use of self-help procedures increase in the future.
Interventions in labor and community frameworks
Within the community health model referred to individuals as responsible for maintaining and improving their health and as stewards of their health. Programs to quit snuff can be considered as activities to promote health and its validity will depend, in addition to the effectiveness and usefulness, adherence to the program.
In this sense we can consider the workplace and the rules of conduct can be adapted to deter and control the behavior of smoking, both health and economic reasons. The employment framework maximizes efficiency in terms of convenience, time, accessibility, control, and monitoring of the subject, which is an invitation to health institutions to intervene in this way.
One example of intervention in the workplace the Smoke Free multicomponent program of Dawley (1982), consists of three phases
- control;
- deterrence and cessation
- snuff. Dawley also
competitions to quit smoking or remain abstinent a given time, is a procedure widely used in community media and / or labor. This usually includes the use of leaflets and cash rewards or other rewards.
radio, television and newspapers have also been used, diffusers as well as prevention campaigns and social assistance / institutional. This author concludes that the results of these programs are very difficult to assess, by suggesting that although the approach is promising, these programs should be viewed with caution until studies appear to solve, or alleviate to a large extent, the methodological shortcomings
Treatment by the medical model
In the clinical setting, and from the medical model addresses the issue by emphasizing mainly on the physiological aspect of nicotine dependence, proposed as methods of intervention, mainly, the council doctor and prescription of nicotine replacement in order to avoid withdrawal symptoms. E1
medical advice is based on the medical consultation. It, therefore, to convince the health problems that the consumption of snuff and should refrain from smoking in front of patients.
Several studies have shown how the council and the doctor's warning about the dangers associated with the use of snuff effective. Especially in subjects with respiratory, cardiovascular and pregnant women. As for the general population, using the simple medical alert, we have obtained rates of abstinence, years of between 3 per 100 and 13 100.
Within the medical model of treatment of tobacco has historically emphasized pharmacological intervention, it usually includes both prescription nicotine replacement in the form of gum or nicotine patches, as anxiolytic or activating substance, in the latter case because many people mention, among the reasons to keep smoking, that will snuff them relaxing or active.
Today, this line of treatment is largely abandoned in the field of medical interventions, having been relieved by the interest aroused by the use of nicotinic receptor agonists, nicotine substitutes, chewing gum and patches.
Prescription gum and nicotine patches is subject to some controversy. Yet we must consider that the cost-effectiveness can not recommend the use of nicotine gum over other effective behavioral procedures.
As an alternative to these approaches are psychological tools, with mixed results regarding its effectiveness, we found that behavioral intervention is, in general, which has been more effective for the cessation of snuff consumption. Main
psychological strategies for smoking cessation
General techniques Although you can consider that all smoking cessation programs established, at least implicitly, a contract between the smoker and the therapist, some treatments employ this strategy as the key therapeutic technique, sometimes as a facilitator of adherence or maintaining abstinence, as a motivating factor, as, for example, the use of monetary incentives has also been used
systematic desensitization to strengthen responses incompatible with smoking, building approach, in which smoking behavior is often associated with anxiety and if they desensitize subjects to the stimuli that precede smoking, then this behavior will decrease. Other researchers suggest that relaxation may be conditioned as an alternative response to smoking.
aversive techniques underlying its effectiveness in three types of assumptions:
- that when the behavior occurs with a frequency and / or a high enough intensity, reinforcing aspects of it disappear and become aversive;
- that when the conduct creates highly aversive consequences likely to take place decreases, and when
- aversion occurs because of intrinsic negative consequences to one's response to smoke, the intensity of the aversion is higher and their maintenance and generalization are more likely.
covert sensitization, in this case, the aversive consequences of it are imaginary, the smoker must play on your imagination in an appropriate manner, conduct and consequences agreed in advance. Basically, after a period of training in the use of imagination, the subject is asked to imagine getting ready to smoke and then imagine that feeling unpleasant sensations such as dizziness, nausea, etc. Also requested that once rejected this imaginary cigarette, have the unpleasant sensations will disappear and be replaced by images that make you feel better and better in general, the effectiveness of the technique, have found very poor results today technique is rarely used, although, as part of a multicomponent program. E1
satiation procedure is instructing the subjects to increase, doubling and even tripling their normal consumption of cigarettes for a week. It is assumed that as the subjects themselves are forced to dislike smoking, cigarette rewarding properties will be phased out, being replaced by other negative properties. Specific techniques
The technique of rapid smoking, smoking cigarettes is your favorite brand, making a breath every five or six seconds for fifteen minutes, one hour sessions with a break between runs of five minutes, during which discusses the negative aspects of the experience and suggests negative cognitions respect to smoking behavior. Another way is to apply the technique in a single trial, which is usually between 20 and 25 minutes, when the smoker does not want to follow the great discomfort it causes. Rapid smoking sessions are held daily at the beginning of treatment and then will gradually spacing. Treatment usually lasts two or three weeks, and subjects tend to quit after the sixth session.
One aspect often given when speaking of the rapid smoking technique is the risk that your application can have on the smoker's health, taking into account the excessive intake of nicotine, carboxyhemoglobin level, possible changes in electrocardiographic etc. that may attach to the application of the technique. However, revisions of these risks appear to indicate that they affect the health of the subject. While it is recommended that treatment subjects older than 40 years.
The technique of retaining the smoke is a better alternative for smokers who accepted the rapid smoking technique, and their results are similar to those achieved with it. Is that the subject hold the smoke of his cigarette in his mouth for 30 seconds while still breathing normally through your nose, after this test rests for 30 seconds and then repeat up to six times the same procedure. In each trial, while the subject is the smoke Mouth says he must concentrate on the unpleasant sensations of the experience. Just as in the case of rapid smoking technique, this strategy is more effective in multi-component programs.
technique gradual reduction of tar and nicotine intake by changing brands is to consume cigarettes containing lower and lower nicotine and tar, forming a more acceptable alternative, he directs his attention to both the highly pharmacological factors associated with the consumption of snuff, as psychological factors of habit. The technique combines, often, weekly change of cigarette brands with lower and lower nicotine content (usually reductions of 30 per 100 in the first week, 60 100 second and 90 for 100 reduction on consumption in the baseline, in the third week) with daily consumption self-registration and representation weekly chart.
recent addition to the treatment of smokers with a new specific technique: the physiological feedback of carbon monoxide (CO). Generally, the technique has been used in a comprehensive program that also used other techniques of treatment, and offered to smokers weekly information on the levels of CO in exhaled air by providing a motivating effect for treatment.
It can be concluded in a general way, that both general and specific techniques, applied in isolation can be considered insufficient.
multicomponent programs for the treatment of smokers
Today, we tend to apply effective methods, but not aversive.
Some ingredients in these programs so that successful treatment seems to be: an intervention method acceptable to smokers, therapists conducting the treatment and maintaining a well-planned strategies, depending on the specific needs exist. In a general, multicomponent programs are presented in three interlinked phases:
- preparation
- neglect and maintenance.
However, today it is considered that more is not always better, because a too complex treatment package may cause the opposite effect and the smoker may find it very difficult to follow
Due to the complexity of smoking behavior and individual differences among smokers, multicomponent programs are essential when a simple method has not proved sufficient to accommodate the full range of problems and smoking.
abrupt cessation versus gradual reduction in consumption
seems that quitting with immediate cessation is a procedure that can be offered to smokers who have willingly and who have been assessed to have skills to cope with withdrawal.
However, smokers often do not meet these conditions of high motivation and / or lack the skills required to meet the withdrawal, in these cases it seems the time has come to quitting smoking in a gradual way, through the gradual reduction cigarette consumption
This approach often raises the problem that customers can reduce the amount of cigarettes smoked, but this reduction is as a result of personal effort that the effect of a real weakening of the links without occur to reach a genuine process of addiction.
With the intention to solve the mentioned problems, Buceta and Thomas (1983) developed a multicomponent intervention program phasing. This program was intended at first to weaken the links between the history, behavior and reinforcing consequences smokers and training skills to combat withdrawal symptoms to nicotine in a second phase, when consumption was reduced sufficiently and the patient was evaluated and mastered the skills that had been trained, they proceeded to cessation. With very encouraging results,
conclusions about the psychological treatment for smoking cessation
Multicomponent programs may increase the utility of intervention programs.
aversive techniques are being disregarded in favor of others such as stimulus control, behavioral contracts, the gradual reduction of nicotine, etc.
Increasingly frequent use of objective tests to evaluate the smoking abstinence.
multicomponent programs can and should still be improved.
seems proven techniques multicomponent programs are aimed, on the one hand, increased motivation, increased perception of self-efficacy to smoking cessation and, finally, the maintenance of abstinence. The
interventional procedures should take into account the following assumptions:
- smoking behavior is a learned habit, strongly consolidated.
- smoking behavior occurs in specific situations, as determined by the antecedent conditions and consequences of behavior, which implies the need for a precise functional analysis of behavior.
- smoking behavior can be eliminated when:
- weakens the link between antecedent stimuli;
- eliminating the reinforcing nature of smoking behavior, and
- amending relevant thoughts and beliefs that support the provision the smoker to smoking behavior.
- Smoking causes physiological effects in the body, such as nicotine dependence and tolerance, so stop abruptly in the consumption of snuff, you can receive the withdrawal of nicotine (APA, 1988). The gradual reduction in consumption can mitigate this problem.
- However, smoke a few cigarettes can be highly reinforcing
- seems appropriate to start with a gradual reduction process, but without allowing them to dilate over time periods of low consumption of cigarettes
- Overlooking increase the likelihood of success, it seems appropriate to draw "Trial periods so that the smoker was successful in the attempt and strengthened their confidence.
- intervention on smoking behavior requires the active participation of clients from the outset.
- The provision of information regarding their progress (for example, CO in exhaled air), may contribute to increased motivation.
intervention is developed in four phases:
- Introduction to treatment and establishment of the line basis of cigarette smoking
- Decomposition of smoking by weakening the links ERC, and training of smokers in various coping skills;
- tests cessation and abstinence, and
- Maintenance of abstinence.
be developed over the first two sessions
Objectives:
- Presentation of the program.
- setting expectations.
- Establishing the baseline, is a measurement of CO
- Explanation of the objectives of the intervention. Description
- standards of the program.
- active Understanding Your Customer.
- Basic explanation of the mechanisms that maintain smoking behavior (antecedents-behavior-consequences).
- Training in the use of self-reports, with them set the frequency of smoking, in order to describe the behavior topographically and to clarify the factors that shape the background conditions and the degree of pleasure felt as a result of each cigarette consumption. Preparation
- lists of pros and cons of quitting smoking with the patient and their families
During this phase aims at the decomposition of smoking by weakening of ties stimulus-behavior-consequences.
Objectives:
:
Strategies:
- Functional analysis of smoking behavior.
- background stimuli used for the implementation of stimulus control techniques.
- rewarding consequences.
- stimulus-behavior-consequences rewarding.
- Cognitions relevant through the information reflected in lists of pros and cons of smoking
- deficits and resources including behavioral deficits and weakening family support links
:
- stimulus control. Is not to demonstrate, on a voluntary basis, smoking behavior in situations in which the set of stimuli the elicitaría, carrying out other alternative behaviors. Reduction
- reinforcing nature of smoking behavior. Delay
- cigarette smoking behavior. Ask
- brush your teeth.
- Remove ashtrays from your home and keep only one
- Prevention response
- Begin the session by the client view of a pack of cigarettes. Turn
- some cigarettes during the session, and let you eat. Training
- alternative responses. Exercised to reject offer of cigarettes. Changing
Strategies:
- Cognitive restructuring: training is intended for smokers, on the one hand, to make them aware of your inner dialogue at the time that have to smoke a cigarette and the other to change their automatic thoughts and internal verbalizations. An important aspect of this procedure is to include elements of cognition, which provide a pleasant consequence of these thoughts (save money, my spouse will feel proud of myself, my children will model a parent showing their value health), so as to eliminate, as far as possible the anxiety associated with prohibiting self-instruction.
- self-instruction training.
- training and acquisition of coping skills. Situations and symptoms that will probably appear at the time of complete cessation and during abstinence: hold com.
- relaxation training to reduce anxiety, irritability, stress and difficulty concentrating (muscle relaxation).
- social skills training. Facilitate assertive behavior by role playing exercises in which patients receive offers and have to be rejected. Maintenance
- Information
- CO in exhaled air.
- daily charts.
- Anticipating the benefits of quitting.
- contingency contracts between client and therapist. To facilitate adherence and as a motivating factor for carrying out treatment activities.
Third phase: Evidence of cessation and abstinence.
When he has acquired some control over the smoking behavior. It is important to note that this is only a test, in order to check how are facing difficulties in principle a person is faced with a long history of smoking, when you begin to live without smoking.
Objectives:
- periodic abstinence test.
- Top of continuous abstinence.
- timing and duration of trial periods. The first test will last between 1 and 3 days or less, and proceed to implement new over longer periods of time up to 7 days without smoking.
- difficulties and test prevention strategies to control them.
- analysis of the difficulties encountered during periods of abstinence and seeking solutions. Strengthening
- achievements during periods of abstinence.
Objectives:
- stay quit. Avoid
- chronicity of possible relapse.
- risk situations more likely to smoke.
- test strategies for controlling high-risk situations.
- Anticipating consequences of living without smoking. Withdrawal symptoms, weight gain and possible occurrence of thoughts that invite smoking and downplay the negative.
- Application of previously learned skills.
EFFECTIVENESS OF PSYCHOLOGICAL TREATMENT FOR SMOKING CESSATION
Effectiveness of psychological techniques in the treatment of smokers
technique rapid smoking, cessation rates of between 6 per 100 and 40 100 in 6 studies conducted
year follow-up retention technique of smoke, of 11.11 per 100 at one year, well below the abstinence rate of 30 per 100 for the twelve months, obtained when the technique of holding the smoke was applied by the gradual reduction, which seems to suggest again, the desirability of placing this technique in intervention programs with other strategies .
gradual reduction, in these studies (abstinence rates ranged from 7 per 100 and 46 100 in the treatments with one year follow up.
Effectiveness multicomponent programs
had the best results are obtained. Most studies on the effectiveness of multicomponent programs have attempted to compare a particular treatment package with other packages that differed only in a single element, without any significant differences that have supported the specific efficacy of a particular strategy
Within the body of research in which aversive techniques have been used as elements of multicomponent programs, abstinence rates achieved at the end of treatment were 75 per 100 for the group subjected to satiation, 50 per 100 for which was applied rapid smoking technique and 75 per 100 for subjects treated with the combination of satiation and rapid smoking. At follow-up, 67 100 of the total group of subjects at the end of treatment and 47 per 100 at six months remained smoke-free.
In Spain, as a motivational strategy asked participants to make a deposit of 20,000 pesetas, which would be returned as remain in the program at different times. Was used as an objective criterion for withdrawal nicotine in urine analysis, and specific program strategies were: self-reports, the graphical representation of consumption, a fixed date of abandonment, stimulus control, relaxation, rapid smoking technique, contingency management, covert aversion and cognitive control. The abstinence rate at end of treatment was 60 100.
The combination of aversive techniques and procedures of self seems to be very useful for the treatment of smokers. Aversive procedures have proved effective in achieving short-term abstinence, but its use has, in addition to the difficulties already mentioned in a previous section, an inherent limitation when applied to the extinction of high occurrence of such behavior as the behavior of smoking. And, when you have not anticipated the availability of alternative responses by the subjects, cessation efforts in consumption, obtained only temporary success (Schwartz, 1987), which justifies that complement other techniques for future maintenance of abstinence.
With the aim of evaluating the personal training for relapse prevention. 587 subjects were randomly assigned to one of the following three conditions follow: 1) skills training (41.3% abstinence), 2) discussion with social support (34.1%), and 3) no treatment (33, 3%). Data from this study seems to conclude that the program works best when adapted to the needs of each smoker
As already noted, gradual reduction of tar and nicotine intake has been the backbone of many programs multicomponent The results at the end of treatment showed an abstinence rate of 66.66 per 100 in the group with gradual reduction of tar and nicotine intake and 12 month follow up, abstinence rates were of 45.83 per 100 in the group which used only a gradual reduction.
Some data on the effectiveness of the proposed program
At the end of the program, 84 100 were abstinent, in the monitoring carried out at six months, 53 100 subjects remained abstinent.
More recently, analyze he difference between the reduction of weekly consumption by a fixed pattern, compared to the treatment activities that were aimed at the decomposition of habit and showed superior efficacy of this treatment compared with that came through a gradual reduction indiscriminately.
In the same study also hypothesized that if the feedback of CO in exhaled air was a useful treatment, the results showed that among subjects who received feedback of CO were produced abstinence rates significantly higher at end of treatment.
Finally, it is remarkable that those subjects who received similar treatment we have proposed in this chapter, focused on the reduction due to the decomposition of habit and coping skills training, and also received feedback from CO, had the highest scores in all measures of efficacy variables.
may be considered relevant to all subjects in the different treatments, but failed to stop consumption, somehow also benefited from the program, since they had a significantly reduced number of cigarettes smoked.
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