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How to treat nicotine dependence in smokers with schizophrenia: improve patients' health, help them kick addiction with this practical approach.

Mr. V, age 49, has stable but symptomatic schizophrenia and a 33-year cigarette smoking history. He is very concerned because his primary care physician told him he has 2 serious smoking-related health problems: diabetes and hypertension. He tried a smoking cessation program for the general public, but it was a poor fit because of his schizophrenia symptoms.

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Despite adhering to his medications (ziprasidone, 20 mg hs; perphenazine, 8 mg hs; lorazepam, 1 mg hs; zonisamide, 200 mg/d, and benztropine mesylate, 2 mg hs), Mr. V has residual auditory hallucinations, paranoid ideation, and impaired concentration and attention. He smokes approximately 1.5 packs per day, particularly when very ill, to alleviate chronic boredom, and to diminish distress from the hallucinations. All of his friends smoke, and they do not support his attempts to quit.

Successfully treating nicotine dependence can seem a formidable challenge in patients with schizophrenia:

* 72% to 90% smoke cigarettes, compared with 21% of the general population1 (Box, page 66). (2-12)

* They tend to smoke heavily, spending about one-third of their incomes on cigarettes. (13)

* Their negative symptoms (such as apathy), positive symptoms (such as disorganized thinking), and cognitive impairment can reduce motivation to quit and adhere to a smoking cessation strategy.

* Sociologic and physiologic aspects of schizophrenia reinforce their smoking habit (Table 1, page 69). (9,12,14-17)

Even so, smokers with schizophrenia can be highly motivated and persistent in attempting to quit. (18) Promising results have been reported in trials when psychopharmacologic treatments are combined with cognitive and behavioral interventions.

This article reviews these empiric studies and suggests practical ways for clinicians to create smoking cessation and relapse prevention plans for individuals with schizophrenia.

Clinical trials of smoking cessation

Inadequate interventions. Conventional regimens--consisting of 8 to 12 weeks with sustained-release bupropion or nicotine replacement therapy (NRT) added to supportive or cognitive-behavioral therapy (CBT) (19)--are well-tolerated by patients with schizophrenia but only modestly effective. CBT alone (or with placebo) has not been effective for smoking cessation in schizophrenia. In clinical trials, abstinence rates have been:

* 4% to 19% after 3 to 6 months with bupropion or NRT and CBT

* [less than or equal to]6% with placebo and CBT. (20-23)

Multifaceted interventions. High-dose NRT patch treatment (2 patches at a time) has not consistently shown additional benefits compared with single-patch treatment. (24,25) However, combining short-acting NRT (gum, lozenge, inhaler, or nasal spray) with a long-acting NRT preparation (transdermal patch) is well-tolerated and has been shown to improve sustained abstinence rates (26) (Table 2, page 70).

In a double-blind, placebo-controlled trial, (27) 51 smokers with schizophrenia were randomly assigned to receive combination NRT (21-mg NRT patch plus [less than or equal to]18 mg/d NRT polacrilex gum prn) added to bupropion SR, 150 mg bid, or placebo. Smoking cessation--defined as quitting on the assigned date and maintaining continuous abstinence for 4 weeks (measured by expired air carbon monoxide <9 ppm and self-report of abstinence at weekly visits)--was achieved by:

* 52% of those receiving bupropion and dual NRT

* 19% who received placebo and the 2 forms of NRT.

Preventing relapse. Relapse is common among all smokers but especially in those with schizophrenia. In clinical trials, 70% to 83% of smokers with schizophrenia who attained abstinence relapsed to smoking within 6 to 12 months of stopping nicotine dependence treatment. (21,22,27,28)

In one clinical trial, >50% of patients achieved 4 weeks of continuous abstinence on a regimen of bupropion SR, 150 mg bid; nicotine patch (21 mg/d); and as-needed nicotine gum ([less than or equal to]18 mg/d). However:

* 31% relapsed to smoking while NRT was being tapered from ~40 to 20 mg/d

* 77% relapsed after nicotine dependence treatment was discontinued. (27)

Longer use of pharmacotherapy may be needed to prevent relapse to smoking in the schizophrenia population. In a recent open case series, 17 of 42 smokers with schizophrenia were able to quit for at least 2 weeks with a combination of bupropion SR, 150 mg bid, and dual NRT. Among those who quit, 13 (76%) remained abstinent for 12 additional months when offered continued pharmacotherapy and tapering CBT (AE Evins, under review).

CASE CONTINUED

Treating nicotine dependence

Mr. V cut down to 10 cigarettes a day during a 4-week motivational enhancement/psychoeducation intervention for smokers with major mental illness. (29) He then enrolled in a 12-week study in which subjects received high-dose dual NRT and bupropion SR or placebo.

Mr. V was reluctant to use the NRT patch because he believed rumors that it could cause a heart attack, especially if he smoked while using a patch. He did try the patch, however, after his clinicians informed him it would increase his chances of quitting.

He received bupropion SR, 150 mg bid; NRT patch, 21 mg/d; and nicotine polacrilex gum, up to 18 mg/d as needed, and tolerated the regimen well. After 4 weeks, he quit smoking on the quit date. His blood pressure--monitored weekly for the first month then monthly thereafter--remained stable throughout the intervention.

Prescribing considerations

Metabolic changes. Smoking--but not NRT--induces hepatic clearance of many psychotropics, and smoking cessation can be associated with increased drug serum levels. Polycyclic aromatic hydrocarbons present in cigarette smoke--but not NRT--induce hepatic aryl hydrocarbon hydroxylases and cytochrome P (CYP)-450 isozymes, primarily CYP 1A1, 1A2, and 2E1, thereby increasing metabolic clearance of medications--such as clozapine--that are substrates for these enzymes.

Smoking cessation is associated with a 30% to 42% reduction in activity of CYP 1A2, and the half-life of this reduction is 27 to 54 hours. Thus, therapeutic drug monitoring and dose reduction of 10% over the first 4 days of tobacco abstinence is recommended to avoid toxicity. If the patient remains abstinent from tobacco, further reducing the antipsychotic dose may be warranted, based on individual assessment.

Weight gain. Patients who quit smoking gain an average of 3 to 5 kg. (30)

Nicotine withdrawal. Patients are used to thinking that nicotine is calming, whereas in reality nicotine and smoking are anxiogenic, and cigarette smoking alleviates the anxiety that comes from nicotine withdrawal. (31) Educate patients about nicotine withdrawal symptoms, which easily can be confused with early signs of a psychotic relapse but are much more time-limited:

* dysphoria and irritability

* anxiety

* insomnia

* reduced heart rate

* restlessness

* difficulty concentrating.

Bupropion SR at 150 mg bid has been well-tolerated when added to antipsychotics and modestly effective for smoking cessation in this population. It has been associated with reduced negative symptoms and greater symptom stability during the cessation attempt--compared with placebo--and is well-tolerated when combined with NRT. (20-22,27)

NRT in a variety of delivery forms has been well tolerated and modestly effective for smoking cessation in schizophrenia. (23,27,28) Combinations of short-acting NRT (gum, lozenge, inhaler, or nasal spray) with the long-acting NRT patch improve long-term abstinence rates in smokers in the general population (26) and may improve abstinence rates in those with schizophrenia. (27) Maintaining the pharmacotherapy used to achieve abstinence may also improve sustained abstinence rates.

Varenicline is a partial nicotinic receptor agonist approved for treating tobacco dependence. No reports have been published on its safety and efficacy for smoking cessation in persons with schizophrenia.

In our experience with open-label varenicline for nicotine dependence in schizophrenia, 8 of 9 patients quit smoking, reported reduced cravings, and remained clinically stable on the agent for 6 to 9 months. All had previously relapsed after discontinuing NRT, bupropion, or the combination.

Controlled trials are needed to discern this agent's place in the treatment hierarchy for smokers with schizophrenia, and several such trials are underway.

10-step office-based approach

CBT alone is not effective for smoking cessation in the schizophrenia population, (22,28) but pharmacologic interventions have not been shown to succeed without concurrent behavioral treatment.

The 10 behavioral treatments described below and the tools listed in Table 3 can be covered in 1 or 2 visits and individualized for a relatively brief, office-based approach. Using the complete list may be ideal, but you can deliver a reasonable behavioral intervention by choosing tasks tailored to each patient's needs. After the initial session, review these interventions at follow-up appointments to reinforce skills.

1 Send a clear and simple message to your patients to quit smoking. If possible, provide a handout about health risks of smoking and benefits of quitting.

2 Elicit the patient's reasons for wanting to quit, and help him or her list these reasons as specifically as possible, such as:

* "I want to have more spending money."

* "I want to improve my health."

* "I want to make my sister proud."

Copy this list on index cards for the patient, and encourage him or her to carry 1 and post others around the house.

3 Prescribe pharmacotherapy, as supported by clinical trial results. Explain the rationale for its use, and encourage adherence. Review proper techniques for using NRT patches and gum, lozenge, inhaler, or nasal spray.

4 Teach the patient skills to cope with cravings. The "4 Ds" are a helpful mnemonic:

* Deep breathe.

* Drink fluids.

* Delay (smoking).

* Do something else.

Give the patient an index card listing the 4Ds, and help him or her memorize them.

5 Discuss the patient's smoking triggers and risky situations. These vary from patient to patient, but common triggers include:

* finishing a meal or drinking coffee

* seeing other people smoking

* psychological stressors or psychiatric symptoms such as anxiety or auditory hallucinations

* boredom, such as waiting for a bus.

Common risky situations include:

* going to a day treatment center where most patients and staff smoke

* visiting a family member who smokes

* dealing with a stressful situation.

Problem-solve with patients about how to cope with smoking triggers (Table 4, page 72). For example, switch from coffee to tea or "decaf," listen to music to cope with auditory hallucinations, use nicotine gum or lozenges while waiting for the bus, or surf the Internet at day treatment instead of going outside to smoke during breaks. Have patients make an index card with a list of "5 things I will do when I feel like smoking."

6 Set a quit date with a detailed "quit day" plan. When the patient has some mastery over triggers and risky situations, work with him or her to prepare for quit day (such as throw out cigarettes and lighters, tell family he or she will be quitting).

Plan the day, often hour by hour, to help the patient make new choices (such as go to the park in the morning instead of the convenience store, do a puzzle while watching TV at night). Schedule in some rewards and pleasant activities to substitute for cigarettes.

7 Work on 'refusal skills.' Patients will likely need to practice saying no to cigarettes offered to them in their social environments. Discuss these skills, and role-play to increase patients' likelihood of success.

8 Provide a 'survival kit' for use during the first week without cigarettes. Include tools to help with cravings and provide distractions, such as a small bag with sugarless gum or candy, toothpicks and straws to chew, rubber bands to keep hands busy, a water bottle, cough drops, healthy snacks, and a card with the 4 Ds.

9 Discuss rewards patients can give themselves instead of cigarettes. This concept will be new to many but is important to help patients depend less on cigarettes for gratification.

10 Call patients on their quit date or the day after to make sure they are on track.

CASE CONTINUED

An improving picture

With CBT, Mr. V grasped that he had to make important changes to quit smoking and reduce his risk of relapse. He embraced the "4 Ds" and successfully adhered to the plan for his quit date. He maintained abstinence through the 12-month relapse prevention treatment period with the same bupropion and NRT dosage he had used to quit smoking (and tapered CBT sessions).

After 12 months, Mr. V's bupropion dosage was tapered to 150 mg/d for 2 weeks and then discontinued, and the NRT patch was tapered to 14 mg/d for 2 weeks, 7 mg/d for 2 weeks, then discontinued. At the same time, he gradually decreased his use of short-acting nicotine gum.

Mr. V realized early in treatment that if he quit smoking he could save $1,000 per year in the price of cigarettes. The camera he bought with the money he saved served as a motivator and helped alleviate the boredom that had kept him smoking.

References

1. Tobacco use among adults: United States, 2005. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly 2006 Oct 27;5(42):1145-8. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542al.htm.

2. Weiser M, Reichenberg A, Grotto I, et al. Higher rates of cigarette smoking in male adolescents before the onset of schizophrenia: a historical-prospective cohort study. Am J Psychiatry 2004;161(7):1219-23.

3. Williams JM, Ziedonis DM, Abanyie F, et al. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect. Schizophr Res 2005;79(2-3):323-35.

4. Tidey JW, Rohsenow DJ, Kaplan GB, Swift RM. Cigarette smoking topography in smokers with schizophrenia and matched non-psychiatric controls. Drug Alcohol Depend 2005;80:259-65.

5. Olincy A, Young DA, Freedman R. Increased levels of the nicotine metabolite cotinine in schizophrenic smokers compared to other smokers. Biol Psychiatry 1997;42(1):1-5.

6. Goff DC, Cather C, Evins AE, et al. Medical morbidity and mortality in schizophrenia: guidelines for psychiatrists. J Clin Psychiatry 2005;66(2):183-94.

7. Himelhoch S, Daumit G. To whom do psychiatrists offer smoking-cessation counseling? Am J Psychiatry 2003;160: 2228-30.

8. Carosella AM, Ossip-Klein DJ, Owens CA. Smoking attitudes, beliefs, and readiness to change among acute and long term care inpatients with psychiatric diagnoses. Addict Behav 1999;24(3):331-4.

9. Esterberg ML, Compton ML. Smoking behavior in persons with a schizophrenia-spectrum disorder: a qualitative investigation of the transtheoretical model. Soc Sci Med 2005; 61(2):293-303.

10. Addington J, el-Guebaly N, Addington D, Hodgins D. Readiness to stop smoking in schizophrenia. Can J Psychiatry 1997;42(1):49-52.

11. Sacco KA, Termine A, Seyal A, et al. Effects of cigarette smoking on spatial working memory and attentional deficits in schizophrenia: involvement of nicotinic receptor mechanisms. Arch Gen Psychiatry 2005;62(6):649-59.

12. Barr RS, Culhane MA, Jubelt LE, et al. The effects of transdermal nicotine on cognition in nonsmokers with schizophrenia and nonpsychiatric controls. Neuropsychopharmacology 2007;Apr 18 [Epub ahead of print].

13. McDonald C. Cigarette smoking in patients with schizophrenia. Br J Psychiatry 2000;176:596-7.

14. Adler LA, Hoffer LD, Wiser A, Freedman R. Normalization of auditory physiology by cigarette smoking in schizophrenic patients. Am J Psychiatry 1993;150:1856-61.

15. Sallette J, Pons S, Devillers-Thiery A, et al. Nicotine upregulates its own receptors through enhanced intracellular maturation. Neuron 2005;46:595-607.

16. Breese CR, Lee MJ, Adams CE, et al. Abnormal regulation of high affinity nicotinic receptors in subjects with schizophrenia. Neuropsychopharmacology 2000;23:351-64.

17. Miller D, Kelly M, Perry P, Coryell W. The influence of cigarette smoking on haloperidol pharmacokinetics. J Clin Psychiatry 1990;28:529-31.

18. Evins AE, Cather C, Rigotti NA, et al. Two-year follow up of a smoking cessation trial in patients with schizophrenia: increased rates of smoking cessation and reduction. J Clin Psychiatry 2004;65:307-12.

19. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. JAMA 2000;283:3244-54.

20. Weiner E, Ball MP, Summerfelt A, et al. Effects of sustained-release bupropion and supportive group therapy on cigarette consumption in patients with schizophrenia. Am J Psychiatry 2001;158:635-7.

21. George TP, Vessicchio JC, Termine A, et al. A placebo controlled trial of bupropion for smoking cessation in schizophrenia. Biol Psychiatry 2002;52:53-61.

22. Evins AE, Deckersbach T, Cather C, et al. A double-blind placebo-controlled trial of bupropion sustained release for smoking cessation in schizophrenia. J Clin Psychopharmacol 2005;25:218-25.

23. Williams JM, Ziedonis DM, Foulds J. A case series of nicotine nasal spray in the treatment of tobacco dependence among patients with schizophrenia. Psychiatr Serv 2004;55:1064-6.

24. Killen JD, Fortmann SP, Davis L, et al. Do heavy smokers benefit from higher dose nicotine patch therapy? Exp Clin Psychopharmacol 1999;7:226-33.

25. Hatsukami D, Mooney M, Murphy S, et al. Effects of high dose transdermal nicotine replacement in cigarette smokers. Pharmacol Biochem Behav 2007;86:132-9.

26. Blondal T, Gudmundsson L, Olafsdottir I, et al. Nicotine nasal spray with nicotine patch for smoking cessation: randomised trial with six year follow-up. BMJ 1999;318:285-8.

27. Evins AE, Cather C, Culhane MA, et al. A double-blind placebo-controlled study of bupropion SR added to high-dose, dual nicotine replacement therapy for smoking cessation or reduction in schizophrenia. J Clin Psychopharmacol. In press.

28. George TP, Ziedonis DM, Feingold A, et al. Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia. Am J Psychiatry 2000;157:1835-42.

29. Steinberg ML, Ziedonis DM, Krejci J, Brandon TH. Motivational interviewing with personalized feedback: a brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence. J Consult Clin Psychol 2004;72(4):723-8.

30. Williamson DF, Madans J, Anda RF, et al. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med 1991;324:739-45.

31. Cooke JP, Bitterman H. Nicotine and angiogenesis: a new paradigm for tobacco-related diseases. Ann Med 2004;36:33-40.

Jennifer D. Gottlieb, PhD

Schizophrenia clinical and research program

Massachusetts General Hospital

Instructor in psychiatry

Harvard Medical School

A. Eden Evins, MD, MPH

Schizophrenia and depression clinical and research programs

Director, Center for Addiction Medicine and addiction research program

Massachusetts General Hospital

Assistant professor of psychiatry

Harvard Medical School

Box Obstacles to smoking cessation for schizophrenia patients

Smokers with schizophrenia are more nicotine-dependent, more likely to become medically ill, and less likely to receive help in quitting, compared with the general population. They:

* begin smoking at a higher rate before diagnosis or treatment for schizophrenia, compared with persons who do not go on to develop the disorder (2)

* smoke each cigarette more intensely, extracting more nicotine per cigarette (3-5)

* have higher rates of smoking-related illness and medical morbidity (6)

* are much less likely to receive physician advice to quit smoking. (7)

Many persons with severe mental illness are misinformed about the risks and benefits of smoking vs nicotine dependence treatment. (8) They often fear and overestimate the medical risks of nicotine replacement therapies. (9) Many believe smoking relieves depression and anxiety, (10) whereas nicotine actually is anxiogenic. Nicotine may improve some aspects of cognitive dysfunction in schizophrenia, which could be a disincentive for patients to quit smoking. (11,12)

Related Resources

* U.S. Public Health Service. Clinical practice guideline. Treating tobacco use and dependence. www.surgeongeneral.gov/tobacco/tobaqrg.htm.

* Agency for Healthcare Research and Quality. Treating tobacco use and dependence: clinician's packet. A how-to guide for implementing the Public Health Service Clinical Practice Guideline. www.ahcpr.gov/clinic/tobacco.

* Massachusetts Department of Public Health. www.trytostop.org.

* Centers for Disease Control and Prevention. Tobacco Information and Prevention Source (TIPS). www.cdc.gov/tobacco.

Drug Brand Names

Benztropine mesylate * Cogentin

Bupropion SR * Zyban

Clozapine * Clozaril

Lorazepam * Ativan

Nicotine/transdermal * Nicotrol, Prostep

* Nicotine/nasal spray * Nicotrol NS

Nicotine/polacrilex * Nicorette

Perphenazine * various

Varenicline * Chantix

Ziprasidone * Geodon

Zonisamide * Zonegram

Disclosures

Dr. Gottlieb reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Evins receives research support from Janssen Pharmaceutica.

RELATED ARTICLE: Bottom Line

Multifaceted treatment with pharmacotherapy and a 10-step cognitive-behavioral intervention increases the likelihood of smoking cessation in patients with schizophrenia. To reduce nicotine dependence, consider combining bupropion SR with patch and short-acting NRT. Develop a'quit day' plan, teach coping skills, build in self-rewards, and provide cues written on index cards to reinforce abstinence.
Table 1 Why up to 90% of schizophrenia patients smoke cigarettes

Sociologic barriers to quitting
* Their social groups often include a high percentage of heavy smokers
* Some fear NRT is 'unhealthy,' causes cardiac arrest, or increases
  nicotine cravings (9) (see Table 2, page 70, for an accurate NRT side
  effect profile)
* They are unlikely to achieve sustained abstinence from a single
  cessation attempt

Physiologic reinforcers and disease factors
* Nicotine may modulate schizophrenia's cognitive dysfunction, including
  sensory gating (a measure of ability to filter out irrelevant
  environmental stimuli) and attention (12,14)
* Nicotine may increase disease-associated reduction in nicotinic
  acetylcholine receptor activity (15,16)
* Smoking (but not nicotine) reduces antipsychotic blood levels by
  increasing metabolism and may reduce side effects of antipsychotic
  medications (17)
* Schizophrenia's cognitive impairment can make smoking cessation
  strategies difficult to follow

Table 2 Suggested pharmacologic approaches for smoking cessation in
patients with schizophrenia

Medication        Dosage                     Specific instructions

Bupropion SR      150 mg bid                 Consider maintenance
                                             treatment if patient
                                             attains abstinence and
                                             tolerates medication well
Varenicline       0.5 mg once daily for 3    No published data in
                  days; 0.5 mg bid for 4     smokers with schizophrenia;
                  days; 1 mg bid ongoing     several trials are underway
NRT patch         21 mg/d to start           Consider combination
                                             treatment with short-acting
                                             preparation; consider
                                             maintenance treatment if
                                             patient attains abstinence
                                             and tolerates medication
                                             well
Short-acting NRT  [less than or equal to]20  Instruct in correct use,
(gum, lozenge,    mg/d as needed for         particularly with gum; for
inhaler, spray)   craving, in 2-mg or 4-mg   patients who attain
                  increments                 abstinence, consider
                                             maintenance of as-needed
                                             short-acting NRT

Medication        Potential side effects

Bupropion SR      Insomnia, anxiety, irritability (usually mild, time-
                  limited); contraindicated in patients with a seizure
                  disorder or who are at high risk for seizures; take
                  care when prescribing in combination with clozapine
Varenicline       Nausea, headache (nausea can be managed in some
                  patients with dose reduction)
NRT patch         Rash, skin irritation, hypersensitivity reaction
Short-acting NRT
(gum, lozenge,
inhaler, spray)

NRT: nicotine replacement therapy

Table 3 CBT tools to help schizophrenia patients quit smoking

Create 'reasons to quit' card
Provide '4Ds' card of 'coping skills when I crave a cigarette' (deep
  breathe, drink fluids, delay (smoking), do something else)
Evaluate and practice problem-solving skills around 'triggers and risky
  situations'
Encourage patient to develop a '5 things I will do when I feel like
  smoking' card
Develop a detailed 'quit day' plan
Role-play cigarette refusal skills
Prepare a smoking cessation 'survival kit'

Table 4 6-step problem-solving skills to help prevent smoking relapse

Step (with sample therapist
question)                         Sample patient response

1. Identify the problem (What is  I am tempted to buy cigarettes every
   the situation that is making   time I walk by the convenience store
   it difficult for you to stay   in my neighborhood
   quit?)
2. Brainstorm solutions (What     1. Walk a different way to the bus so
   are some possible solutions?)     I don't pass the convenience store
                                  2. Tell the people at the convenience
                                     store that I quit smoking
                                  3. Don't carry extra money so I can't
                                     buy cigarettes
3. Evaluate pros and cons (What   Walking a different route to the bus:
   are the good things and the      Pros: less temptation, more exercise
   not-so-good things about each    Cons: longer trip, different routine
   possible solution?)            Don't carry money:
                                    Pros: can't buy cigarettes
                                    Cons: can't buy other things; might
                                    need money in an emergency
4. Pick a solution (Which         Walk a different way to the bus so I
   solution or combination of     don't pass the store
   solutions looks the best?)
5. Make a plan (What do you need  I need to test out other routes to the
   to do to try it out?)          bus, set alarm earlier so have enough
                                  time for longer route
6. Rate the solution (How well    Since I planned my route in advance, I
   did it work? Do you need to    don't feel nervous about it. I think
   try something else?)           about cigarettes less in the morning
                                  now
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Author:Gottlieb, Jennifer D.; Evins, A. Eden
Publication:Current Psychiatry
Article Type:Case study
Geographic Code:1USA
Date:Jul 1, 2007
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