Please email the editor or post them to DDN, CJ Wellings Ltd, Romney House, School Road, Ashford, Kent TN27 0LT. Letters may be edited for space or clarity.
The power of e-cigs
I am writing in support of Dr Neil McKeganey and his view on the prescribing of e-cigarettes (DDN, February, page 18). As a proponent of harm minimisation in all its forms and bearing in mind the alarming percentage of service users in their forties and fifties with a diagnosis of COPD, anything that can reduce the numbers smoking tobacco is to be welcomed.
In 2008 at Build on Belief we did an impact evaluation and asked our service users how many of them smoked tobacco. The answer was 73 per cent – more than three times the national average. In 2014 we repeated the evaluation and asked the same question. The answer didn’t change by a single percentage point and remained at 73 per cent. Then, in 2016 we did another, smaller survey in one borough and were astonished to discover the percentage of tobacco smokers had dropped to 50 per cent.
The following year, we thought to ask how many of them used e-cigarettes. The answer was 23 per cent, the exact percentage of the recorded drop in tobacco smokers. Interestingly, the great majority of those who had switched to vaping were in treatment and identified as being in recovery.
It seems self-evident that there is a useful piece of work to be done with those service users who smoke, while they are in treatment, to encourage them to make the switch to vaping as a part of moving toward a healthier lifestyle if they are unwilling or unable to give up tobacco. The health benefits would be enormous, and our research suggests that a significant number would, with a little support, do so.
Tim Sampey, chief executive, Build on Belief
Road to recovery
I sincerely found the experience of the DDN conference really amazing as a new peer mentor for Turning Point Leicester. I had no help from the armed forces and left after 30 years both as an engineering apprentice and soldier, followed by becoming an officer with the rank of captain.
I was simply told ‘as an officer, sort yourself out!’ I had a well-won nervous breakdown and PTSD that will be with me for life. I take professional counselling once a month and have been abstinent from alcohol for nearly four years now. I left the armed forces 20 years ago and never once as a family man thought a road to hell was ahead. I now enjoy life with my lovely wife of some 47 years – without her support I know I would not be here.
Trevor Mills, by email
Get the picture
Natalie Davies’ outstanding analysis of the Cycle of Change (DDN, February, page 20) was let down by your illustration. Natalie’s discussion demonstrates that the stages of change model is a really good description of what happens when people make a significant shift in habits and behaviour.
When it was first introduced in the early 1980s some in the UK fell on it a little too enthusiastically. Whole services were reconfigured to reflect the stages as though they were discreet, evidence-based stepping stones in a process. In truth, there was probably little harm done. A good description is better than what we had before. It certainly chimed with the emergence of broader, more nuanced understandings of alcohol and other drug use that were overtaking simplistic, diseased models.
The stages of change model has become a staple of addictions training presentations ever since. It is accessible. Many of us will have lost of count of the number of times we’ve been presented with it, often by people who apparently haven’t read any of the articles and books the originators produced.
How many of these trainers and presenters have noted that since 1992 the term ‘relapse’ no longer featured. The diagram describing the model changed from a circle to a spiral. In 1994 the new diagram featured in a book (for the benefit of those of us who don’t have easy access to academic journals).
Your illustration includes the ‘r’ word. Most addictions trainers continue to use the older diagrams and spout on unthinkingly about Relapse (sic) despite the fact that it is over 25 years since the original authors eschewed the ‘r’ word in their model. Obviously there are reasons for this. These probably include:
• It’s a challenge to keep up to date
• People don’t read journals, or books
• It is hard to draw a spiral
• We don’t like change apparently (especially to our favourite model of change)
• The diseased models are alive and sick and worryingly continue to infect the field and the language we use to train new entrants and the wider community.
New ideas take time to catch on. Prochaska & DiClemente’s model was an exception. Their Cycle of Change is here to stay. It has been more than a quarter of a century since they (with Norcross) stopped talking about relapse. Anyone claiming to cite them to add legitimacy to their views on alcohol and other drugs should stop using the ‘r’ word right now.
As a field, we have a duty to advocate for the people who need our services. We do them no favours by education and communications that wilfully misrepresents the work of key academics. We can’t really expect journalists and politicians to get reporting and policy right if we’re 25 years out of date (and counting) ourselves.
Prochaska, J,O., DiClemente C.C., Norcross J.C. (1992) In search of how people change. Applications to addictive behaviors. Am Psychol 47(9):1102-14
Prochaska, J.O., Norcross, J.C. & DiClemente, C.C. (1994). Changing for Good. New York: Morrow.
Trevor McCarthy, independent consultant
Natalie Davies, assistant editor, Drug & Alcohol Findings responds:
We would like to thank Trevor McCarthy for his comments on our article about Prochaska and DiClemente’s ‘stages of change’ model – especially for clarifying that the diagram featured is no longer an accurate depiction. There are many diagrams of the stages of change in circulation, but just looking at a sample of publications from the originators, it is apparent that they went on to embrace a way of describing the stages where a lapse or relapse did not necessarily mean that people regressed all the way back to where they started.
They recognised that people can learn from their mistakes or what didn’t work, and try something different the next time. For example, this was illustrated in 1992 with a ‘spiral’ diagram (each loop in the spiral taking people closer to lasting recovery), and in 2003 with an adapted ‘cycle’ diagram placing the first stage (pre-contemplation) outside the circle to illustrate that people re-‘cycling’ through the stages would likely not return to where they started. We have made changes to the hot topic on the Effectiveness Bank website to reflect this, and would encourage readers to visit: http://findings.org.uk/PHP/dl.php?file=cycle_change.hot