Smoking cessation with weight-gain prevention

1. Introduction

Version followed: there is no single founder or manual. This guide puts four documented protocol families on top of a standard cognitive-behavioural cessation core: (A) weight-concerns CBT (Perkins et al. 2001, the CONCERNS arm in Levine et al. 2010, and its quitline adaptation Weigh2Quit, Bush et al. 2012); (B) the acceptance-based distress-tolerance programme for weight concern, DT-W or "WE QUIT" (Bloom et al. 2017); (C) personalised behavioural weight-gain prevention as tested in UK stop-smoking services (Lycett et al. 2010 IDAP protocol; the SWISSS referral trial) and summarised for practitioners in the NCSCT Briefing 9; and (D) adjuncts: supervised exercise (Marcus et al. 1999, Commit to Quit) and a pre-quit weight-stability phase (protocol NCT03156660). The cessation core follows the structure of Brown's (2003) CBT manual and the US Public Health Service guideline (Fiore et al. 2008), as used in DT-W. The Cochrane review (Hartmann-Boyce et al. 2021) is used only to decide which variant to choose and what to avoid. [source: Cochrane 2021 record; Bloom et al. 2017; Bush et al. 2012; NCSCT Briefing 9]

What it is. This is not one therapy. It is a research tradition and a set of programmes that add work on weight, or on weight worry, to standard smoking-cessation treatment. They serve smokers (in the trials, mostly women) for whom fear of gaining weight blocks quitting or drives relapse. There are two strands. One tries to limit actual weight gain through personalised eating and activity planning, weighing, exercise or diet programmes. The other tries to reduce the power of weight concern, either by challenging it (CBT) or by accepting it and acting on values (ACT/distress tolerance). [source: Cochrane 2021 record; Bush et al. 2012; Bloom et al. 2017]

Core idea of change. On average, quitting brings some weight gain, and its size varies widely between people. Many smokers use cigarettes partly to control appetite and weight, so worry about weight, hunger and body-image distress act as smoking triggers. People change when weight concerns lose their grip as triggers, and when hunger and eating are managed without restrictive dieting (which raises urges). Abstinence always comes first. The two strands explain it differently. The CBT strand works by correcting catastrophic beliefs about weight and discouraging dieting. The ACT strand works by increasing willingness to have weight-related thoughts and feelings while acting on the value of quitting. [source: NCSCT Briefing 9; Bush et al. 2012; Bloom et al. 2017]

2. Framework

Choosing a variant. [source: Cochrane 2021 record; NCSCT Briefing 9; Bush et al. 2018] [synthesis for the decision rule]

The client is worried about gain and the worry threatens the quit attempt → Variant A (weight-concerns CBT) or B (acceptance-based).
The client is overweight, already gaining, or at medical risk from gain (e.g. diabetes) → Variant C (personalised support, or referral to a structured weight programme) on top of normal cessation support.
The client is sedentary and willing to exercise → add D (supervised exercise).
Avoid giving detailed generic weight education with no personalised assessment, planning or feedback. Cochrane found it did not reduce gain at 12 months and may lower quit rates (low certainty).
On telephone quitlines, weight calls delivered at the same time as cessation calls were linked to lower abstinence than quit-only or sequential delivery (Best Quit trial). For brief or remote services, prefer "quit first, then weight".

Variant A: weight-concerns CBT. [source: Bush et al. 2012 description of Perkins 2001; NIDA 2001 release; ScienceDaily 2010 on Levine 2010]

Format: closed groups of weight-concerned women; 10 sessions of 90 minutes over 7 weeks. Weight-concern sessions are interspersed with standard cessation counselling. In the original trial no medication was given. Levine et al. (2010) added bupropion or placebo for 6 months alongside about 3 months of counselling; the session count in that trial was not verified here [uncertain].
Telephone adaptation (Weigh2Quit): 5 standard quit-coach calls + 3 weight-coach calls, all within about 4 months, with weight concerns raised in every call.
Contents: education on post-quit gain; identifying and challenging maladaptive thoughts about weight and shape; discouraging restrictive dieting; encouraging acceptance of moderate gain; self-monitoring of weight thoughts; and in the phone version, physical-activity and healthy-snack goals.
The session-by-session order of the original manual is not given in the sources [uncertain]. The manual is published in Perkins, Conklin & Levine (2008), Cognitive-Behavioral Therapy for Smoking Cessation.

Variant B: DT-W / WE QUIT (acceptance-based). [source: Bloom et al. 2017]

Format: one 60-minute individual session + eight weekly 90-minute group sessions + one 20-minute individual phone call between groups 4 and 5. Two co-leaders follow a structured manual.
Phases:
- Groups 1–2: weight-focused ACT only (psychoeducation, values, weight concern as a trigger, costs of control, acceptance and defusion).
- Group 3: pre-quit (self-as-context, willingness, quit preparation, self-monitoring, triggers, NRT instruction).
- Group 4: quit date (extended review of quit experience; appetite awareness and committed action begin).
- Groups 5–8: post-quit relapse prevention plus mindful eating, mirror exposure and defusion (group 6), and values and committed action (groups 7–8).
From the individual session onward, time is split about equally between ACT content and standard cessation content.

Variant C: personalised behavioural weight-gain prevention (UK stop-smoking services). [source: Lycett et al. 2010 protocol; SWISSS trial; NCSCT Briefing 9]

Standard withdrawal-oriented behavioural support runs weekly from about 2–3 weeks before quit day to 4 weeks after, with NRT or varenicline.
Weight support starts around quit day (Lycett protocol: from one week before quit day) and continues to about 12 weeks after quitting. Visits are frequent early and taper. In the trials it was delivered by trained practice nurses with dietitian and GP backing, or by referral to a commercial weight programme starting near the quit date.
Contents: a personalised assessment; about three agreed goals (food choice, eating behaviour, activity); an individual energy prescription and food-group plan set by a dietitian or nurse, not the therapist; periodic weighing; and review.

Variant D: adjuncts.

Supervised exercise (Commit to Quit): supervised vigorous exercise three times a week for 12 weeks alongside a weekly cessation group, for previously sedentary women. Wellness sessions served as the contact control. [source: ScienceDaily 1999 on Marcus et al. 1999]
Pre-quit weight-stability phase (NCT03156660): an 8-week weight phase before cessation, aimed at keeping weight stable (or, in another arm, at weight loss) with self-weighing and weekly feedback. It is followed by a 6-session group cessation programme (preparation → quit week with an individual problem-solving call → relapse prevention), then monthly booster sessions on weight problem-solving. [source: NCT03156660 protocol v2.4] Outcomes of this protocol were not found [uncertain].

Generic phase map used in this guide [synthesis, assembled from the protocols above]:

Assessment and engagement (1 session). Goal: smoking history, weight history including gain at past quits, size and nature of weight concern, eating-disorder screen, medical risk, choice of variant. Move on when the client has chosen a quit approach and agreed how weight will be handled (quit first, concurrently, or a pre-quit stability phase).
Preparation (1–3 weeks). Goal: education, self-monitoring of smoking and triggers, weight concern named as a trigger, pharmacotherapy arranged, quit date set, hunger plan in place. Move on when the quit date is fixed and the client has a written coping plan.
Quit date and quit week. Goal: get through the first days. Daily coping, withdrawal and hunger management, and an extra contact during the week. Move on after a first abstinent week, or re-plan after a lapse.
Early abstinence (weeks 2–4/8). Goal: relapse prevention, plus weight-concern work (A/B) or personalised eating and activity plan (C). Weigh periodically, not obsessively. Move on when abstinence is stable and the weight plan is running without crisis.
Consolidation and maintenance (to about 3 months, with boosters). Goal: keep abstinence, catch rapid gain early, step up to structured weight support if needed, plan for the long term (gain is rarely temporary unless acted on). End when the client can name their own warning signs and plans.

3. Guiding principles

Each principle with its practical meaning. [source: NCSCT Briefing 9; Bush et al. 2012; Bloom et al. 2017; Cochrane 2021 record; synthesis where marked]

Abstinence is the primary outcome. When weight and quitting compete, protect the quit attempt; weight work must never become the reason someone keeps smoking.
Give accurate, individualised expectations. Tell clients the average first-year gain and its wide spread: some people gain little or lose weight, some gain a lot. Most of it comes in the first three months. Do not promise "you won't gain".
Health benefit outweighs moderate gain. Use this as a fact in psychoeducation, not as a lecture or a reason to dismiss the client's worry.
Do not start restrictive dieting during the quit attempt. Hunger raises urges to smoke. Encourage regular meals, satisfying healthy snacks and water. The exception is a structured, supervised plan that a dietitian or programme delivers.
Personalise rather than educate generically. Assess, plan and give feedback with the client. A leaflet-style lecture on calories may cost quit rates.
Weight concerns are smoking triggers. Treat a body-image thought or a tight waistband as a high-risk situation, like coffee or stress, with a planned response.
Accept moderate gain. Both the CBT and ACT strands aim at willingness to tolerate some gain for the sake of quitting, not at a weight-gain ceiling of zero.
CBT stance: test the thoughts. In Variant A, treat beliefs such as "if I gain a few pounds I'll be disgusting" as hypotheses to examine.
ACT stance: change the relationship with the thoughts, not their content. In Variant B, do not dispute weight thoughts. Help the client notice them, make room for them and act on values.
Values over control. Make clear what quitting is for and how controlling weight with cigarettes has worked out (Variant B).
Monitor weight, but not too often. Periodic weighing catches rapid gain. The NCSCT briefing warns against very frequent (daily or weekly) weighing during a quit attempt because it may raise distress. Note that one US protocol (NCT03156660) used daily self-weighing pre-quit [uncertain: the sources conflict; pick one rule and explain it to the client].
Act early on rapid gain. If gain is fast, step up to structured support or referral rather than waiting.
Fit the sequence to the setting. In brief or telephone services, quit first and treat weight afterwards (or sequentially). In intensive face-to-face programmes, concurrent work is acceptable.
Pharmacotherapy is part of the package. NRT, varenicline and bupropion each modestly blunt gain while used. Coordinate with the prescriber; the therapist does not advise on doses.
Collaborate and use the client's own goals. Agree on about three concrete goals and review them. Praise attempts at homework rather than criticising non-completion.
Screen for disordered eating and avoid weight stigma. [synthesis] Weight-concerned smokers include people with bulimic or restrictive patterns. Neutral language and a non-dieting stance protect them.
Weight-neutral, respectful language. [synthesis] Talk about health behaviours, hunger and comfort, not "getting fat".

4. Intervention inventory

There are 34 entries, grouped by strand. "Variant" names the protocol each comes from. All example wording is my own (illustrative) unless quoted and cited. Copyrighted manuals and worksheets (Brown 2003; Perkins et al. 2008; the Weigh2Quit workbook; Craighead's Appetite Awareness Workbook; the DT-W manual) are described here, not reproduced.

4A. Shared cessation core

The cessation core follows the structure described in DT-W: Brown 2003 / Fiore et al. 2008. [source: Bloom et al. 2017; NCT03156660 protocol; Lycett et al. 2010; SWISSS]

1. Intake assessment of smoking and weight concern

Purpose / when: first contact. Choose the variant and spot risks.
Steps:
1. Take the smoking history: amount, past quit attempts, what led to relapse.
2. Ask directly how much weight the client would accept gaining, and whether past quits brought gain. The NCSCT briefing calls past gain possibly the strongest predictor, though evidence is limited.
3. Ask whether weight worry or hunger contributed to past relapses.
4. Note medical conditions where gain matters (diabetes, obesity-related disease) and current medications.
5. Screen briefly for binge eating, purging or restriction [synthesis].
6. Record baseline weight if the client consents, measured privately.
7. Summarise and agree an approach: quit first, concurrent work, or a pre-quit stability phase.
Example language (illustrative): "Some people tell me the thing that scares them most about stopping is their weight. Is that part of it for you? What happened to your weight the last time you stopped?"
Watch for: refusal to accept any gain, a sign of high weight concern (Variant A/B indicated). Eating-disorder signs mean you should refer for assessment before any eating plan [synthesis]. Being working: the client names weight worry openly and links it to smoking.

2. Psychoeducation on post-cessation weight gain

Purpose / when: first or second session, in every variant. Replace catastrophic or false beliefs with accurate expectations. In DT-W this also covers the history of cigarettes being marketed for slimming, nicotine's effects on weight, and why gain happens.
Steps:
1. Ask what the client expects.
2. Give the facts in plain language. There is an average gain in the first year, with a wide spread around it: about a quarter gain little or nothing and about a quarter gain a lot. Most comes in the first three months. It usually does not reverse on its own unless the person acts. Cessation medicines blunt gain a little while they are taken. The health gain from quitting outweighs the risk of moderate gain.
3. Check understanding.
4. Link the facts to the plan.
Example language (illustrative): "Averages hide a lot. Some people barely change, some gain more. What we can do is watch it and act early if it moves fast, without putting your quit at risk."
Watch for: information alone without a personalised plan (Cochrane: generic detailed education may lower quit rates). Keep it brief and tie it to action. Being working: the client's predicted gain becomes more realistic and their distress drops.

3. Setting the quit date and pre-quit preparation

Purpose / when: preparation phase. In DT-W the quit date is at group 4 (week 4). In NCT03156660 it is set at the first cessation session. In UK services, support starts about 2 weeks before quit day.
Steps:
1. Choose a date with the client, avoiding predictable high-stress days.
2. Plan pre-quit rituals, such as removing ashtrays and lighters and cleaning the car.
3. Optionally reduce cigarettes per day beforehand (NCT03156660).
4. Explain withdrawal and what the quit week will feel like.
5. Arrange pharmacotherapy with the prescriber.
6. Write a hunger plan (see 27).
Example language (illustrative): "Let's pick the day and work backwards: what needs to be gone from the house, and what will you eat when the urge hits at 3pm?"
Watch for: repeatedly postponing the date because of weight worry. Treat that as a cue for weight-concern work (A/B). Being working: a fixed date and a written plan.

4. Self-monitoring of smoking and triggers

Purpose / when: pre-quit. Map when, where and why the client smokes, including weight and appetite triggers.
Steps:
1. Give a simple log: time, situation, feeling, urge strength, and whether hunger or a body-image thought was present.
2. Review the log in session.
3. Sort triggers into external (places, people) and internal (feelings, thoughts, including weight thoughts).
Example language (illustrative): "Over the next week, every time you light up, jot down what was going on and whether you were hungry or thinking about your weight."
Watch for: incomplete logs; most DT-W pilot participants did not complete written homework. Accept partial logs or app entries, and praise any completion. Being working: the client spots patterns themselves.

5. The "three As" for non-weight triggers

Purpose / when: pre-quit and quit week, as the core coping skill for high-risk situations (DT-W standard component).
Steps: for each trigger, choose one strategy:
- Avoid the situation, at least early on.
- Alter it, for example by changing the routine or sitting somewhere else.
- Use an Alternative behaviour in place of smoking, such as a walk, gum, water or a call. Then write the plan down and rehearse it.
Example language (illustrative): "After dinner is your strongest cigarette. Can you avoid it, change it, or put something else in its place?"
Watch for: food becoming the default "alternative" for every trigger. Steer toward non-food alternatives, or planned snacks (see 27). Being working: urges in the situations you planned for are survived without smoking.

6. Enlisting social support

Purpose / when: pre-quit through maintenance (DT-W standard component). The group format provides support of its own.
Steps:
1. Identify one or two supporters.
2. Decide exactly what help to ask for, including on weight: for example, "don't comment on my weight" or "walk with me".
3. Rehearse the request.
4. Identify people who undermine the quit, such as smokers at home or people who make weight comments.
Example language (illustrative): "Who would you want in your corner, and what would you actually ask them to do, or not to do?"
Watch for: partners who sabotage, or who make weight comments. Being working: the client reports concrete help received.

7. Coordinating pharmacotherapy

Purpose / when: before quit day. Medication raises quit rates and modestly reduces gain while it is used. In Levine et al. 2010, bupropion added to weight-concerns CBT improved abstinence, but it gave no benefit with standard counselling.
Steps:
1. Ensure the client has a prescriber or service consultation.
2. Teach correct use, as DT-W does in the session before quit day.
3. Review side effects and adherence at each contact.
4. For clients for whom gain is a serious medical risk, the prescriber may consider longer-term NRT as a second-line option (NCSCT). The therapist gives no dose advice.
Example language (illustrative): "Your medication helps with cravings, and it may also slow weight gain a little while you take it. How are you getting on with it?"
Watch for: stopping medication early because of nausea, or because the client fears gain when it stops. Being working: consistent use through the course.

8. Quit-week support and an extra contact

Purpose / when: the hardest phase, with the most relapse. NCT03156660 adds an individual phone problem-solving call during quit week. DT-W has an extended quit-date session and a mid-programme phone call.
Steps:
1. Debrief each day: urges, withdrawal, hunger, sleep.
2. Problem-solve the worst moment.
3. Renew the plan for the next 24–48 hours.
4. Reinforce every smoke-free day.
Example language (illustrative): "Talk me through yesterday's worst moment. What did you do, and what would you do differently today?"
Watch for: sudden heavy snacking or distress about weight in week 1. Normalise it and use 24/27 rather than imposing restriction. Being working: the client is abstinent and the urges feel manageable.

9. Relapse prevention and lapse management

Purpose / when: after quit day, in all variants (DT-W groups 5–8; NCT03156660 phase 3; standard UK support to week 4).
Steps:
1. List the upcoming high-risk situations, including weight triggers such as clothes feeling tight or weighing day.
2. Rehearse responses to each.
3. Plan lifestyle changes that support abstinence.
4. Agree what a lapse means: an event to learn from, not a failure. The next step after a lapse is to get rid of the cigarettes and contact the counsellor.
Example language (illustrative): "If you get on the scales and see a number you hate, that is a high-risk moment. What's your plan for the next ten minutes?"
Watch for: all-or-nothing thinking after a lapse ("I've blown it"). Being working: lapses are followed by a quick return to abstinence.

4B. Variant A: weight-concerns CBT

The components below are those listed for Perkins et al. 2001 and Weigh2Quit. The step-by-step procedures are standard CBT methods applied to these targets: that operationalisation is [synthesis], because the original session scripts are not drawn on [uncertain]. [source: Bush et al. 2012; NIDA 2001; ScienceDaily 2010]

10. Identifying maladaptive weight and shape thoughts

Purpose / when: early sessions. Make automatic thoughts about weight visible, and show how they lead back to smoking.
Steps:
1. Explain the thought–feeling–behaviour link using a weight example.
2. Elicit recent hot thoughts. Situations to ask about: looking in a mirror, clothes fitting, eating a large meal, being weighed.
3. Rate how strongly the client believes each thought and how distressed it makes them.
4. Trace the chain to smoking or to the decision to delay quitting.
Example language (illustrative): "When your jeans felt tight on Tuesday, what went through your mind? And what did you feel like doing next?"
Watch for: thoughts typical of eating-disorder cognition, such as worth defined entirely by weight, or a compensatory urge. Being working: the client catches thoughts in real time.

11. Self-monitoring of weight and body-image thoughts

Purpose / when: between sessions, throughout. Weigh2Quit used workbook forms for tracking unhelpful weight thoughts.
Steps:
1. Give a simple record: situation, thought, feeling and rating, what the client did (smoke, eat, avoid), and an alternative response.
2. Review it at each contact.
3. Pick one recurring thought to work on.
Example language (illustrative): "Each time a weight thought really bothers you this week, note it down with the situation. We'll pick the loudest one to work on."
Watch for: monitoring that increases rumination. If so, reduce it to one entry a day. Being working: entries show lower distress ratings over time.

12. Cognitive restructuring of weight concerns

Purpose / when: core of Variant A, from pre-quit onward. Challenge catastrophic and inaccurate beliefs about gain, its meaning and its consequences.
Steps:
1. Take one thought.
2. Examine the evidence for and against it. Use facts from intervention 2, such as how large typical gain is and the health trade-off.
3. Look for thinking errors: catastrophising, all-or-nothing thinking, mind-reading about how others will judge them.
4. Write a balanced alternative.
5. Re-rate belief and distress.
6. Plan a behavioural test where possible, for example noticing whether anyone actually comments.
Example language (illustrative): "You said a few pounds would make you 'huge'. If a friend gained a few pounds after stopping smoking, would you see her that way? What would be a more accurate way to put it?"
Watch for: arguing or persuading instead of guided discovery. Being working: belief in the thought falls and the client stops postponing the quit.

13. Discouraging restrictive dieting (non-dieting stance)

Purpose / when: pre-quit and early abstinence. Dieting while quitting raises hunger and urges, and in Perkins 2001 the weight-control (diet) arm did worse on abstinence than the weight-concern arm.
Steps:
1. Ask about any plans to diet or skip meals.
2. Explain why restriction undermines quitting.
3. Agree on regular meals and planned snacks instead.
4. Revisit structured weight work later, once abstinence is stable.
Example language (illustrative): "Cutting right back on food while you're stopping smoking is like taking on two hard jobs at once, and hunger makes cravings louder. For now let's aim for regular meals and decent snacks."
Watch for: covert restriction such as skipped breakfasts. Being working: no meal-skipping, and hunger-linked urges decline.

14. Building acceptance of moderate weight gain (CBT version)

Purpose / when: throughout Variant A. Shift the client's acceptable gain from "none" toward "moderate, as the price of quitting".
Steps:
1. Ask how much gain the client would accept now.
2. Weigh costs and benefits: health, money, smell and fitness gains against modest gain.
3. Use restructuring (12) on the client's "unacceptable" threshold.
4. Re-ask the acceptable-gain question at intervals and track the change.
Example language (illustrative): "Earlier you said zero. Given what you'd get back from quitting, what amount could you live with, at least for this year?"
Watch for: acceptance that is only verbal while the client is secretly dieting. Being working: the client's stated acceptable gain rises and abstinence holds.

15. Goal setting for quitting and for unproductive weight thoughts

Purpose / when: each contact (Weigh2Quit: realistic goals for quitting and for reducing unproductive weight thoughts, plus physical-activity and healthy-snack goals set with the weight coach).
Steps:
1. Set one quit goal and one weight-thought goal per week, for example "when I notice a body-check, I'll do one restructuring entry".
2. Optionally add one activity or snack goal, defined by the client and specific to them.
3. Review progress next contact and adjust.
Example language (illustrative): "What's one thing you'll do this week about the cigarettes, and one thing about those weight thoughts?"
Watch for: goals that are too many or too large. Being working: at least partial goal completion each week.

4C. Variant B: acceptance-based DT-W (WE QUIT)

The session placement below follows Bloom et al. 2017. The DT-W manual itself is not drawn on. Where exercises draw on standard ACT metaphors, they are named as the paper names them. [source: Bloom et al. 2017]

16. Weight-focused psychoeducation (ACT frame)

Purpose / when: individual session and group 1. Covers the history of smoking promoted for weight control, nicotine's effects on weight, and the reasons for post-quit gain. These are presented as context, not as a problem to be fixed.
Steps: present the material briefly, invite reactions, and name the client's weight worries as understandable.
Example language (illustrative): "For decades cigarettes were sold as a way to stay slim, so it makes sense that the idea is stuck in your head."
Watch for: psychoeducation drifting into reassurance or disputing. Being working: clients openly share their weight fears.

17. Values clarification (smoking vs weight)

Purpose / when: individual session and groups 1, 4, 7 and 8. Clarify what matters, and distinguish values (directions) from goals (endpoints).
Steps:
1. Ask what the client wants their life to be about in health, family and work.
2. Explore which values smoking serves and which weight control serves.
3. Separate values from goals: "being healthy" versus "a particular dress size".
4. Write down the value behind quitting.
Example language (illustrative): "If quitting smoking were a step in some direction, what direction would it be?"
Watch for: "values" that are really rules about weight. Being working: the client can name a quit-supporting value and refers to it under stress.

18. Weight concerns as internal smoking triggers

Purpose / when: individual session and group 1. Separate external triggers from internal ones, and identify weight and body-image concerns as internal triggers.
Steps:
1. Using the trigger log (4), sort the triggers.
2. Highlight the internal ones linked to weight.
3. Plan to meet these with acceptance skills (19–22) rather than with smoking.
Example language (illustrative): "Notice that some of your cigarettes aren't set off by places at all, but by a thought about your body."
Watch for: clients who can't detect internal triggers. If so, use in-session imagery of a recent episode. Being working: weight thoughts are reported as "just another trigger".

19. Examining the costs of controlling weight concerns (creative-hopelessness style)

Purpose / when: individual session and group 2. Review past attempts to control or avoid weight worries, especially ones that led back to smoking.
Steps:
1. List the strategies used to get rid of weight worry: smoking, dieting, avoiding mirrors, constant weighing.
2. For each, ask whether it worked short term, whether it worked long term, and what it cost.
3. Draw out the pattern: control efforts keep the worry going and keep the person smoking.
Example language (illustrative): "What have you tried to make the weight worry go away? How well has that worked over the years, and what has it cost you?"
Watch for: hopelessness about quitting rather than about the control agenda. Keep the focus clear. Being working: the client becomes curious about a different approach.

20. Cognitive defusion from weight thoughts and smoking rationalisations

Purpose / when: groups 2, 6 and 7. Treat weight-related thoughts and "just one" rationalisations as mental events rather than commands. Pilot participants found the "leaves on a stream" and "passengers on a bus" metaphors helpful.
Steps:
1. Introduce defusion with one metaphor. In leaves on a stream, the client places each thought on a leaf and watches it float by. In passengers on the bus, weight thoughts are noisy passengers while the client keeps driving toward their value.
2. Practise in session with the client's own weight thoughts.
3. Assign brief daily practice.
Example language (illustrative): "Let 'I'll get fat if I quit' be one of the passengers. It can shout from the back. You're still the one steering."
Watch for: defusion used to get rid of thoughts, which is a control agenda again. Being working: thoughts are present but have less pull on behaviour.

21. Self-as-context with breathing

Purpose / when: group 3 (pre-quit). Help the client observe thoughts and feelings from a non-judging vantage point.
Steps:
1. Lead a short breathing exercise.
2. Invite the client to notice thoughts, body sensations and urges coming and going.
3. Point out the part of them that notices and stays the same.
4. Link this to staying steady during cravings.
Example language (illustrative): "Notice the thought about your stomach... and notice that you are the one noticing it."
Watch for: dissociation or panic during breath focus. If it occurs, use eyes-open grounding [synthesis]. Being working: the client describes "stepping back" during urges.

22. Willingness commitment

Purpose / when: group 3, just before quit day. The client commits to making room for weight-related thoughts and feelings, and to acting on values whatever those thoughts and feelings are. This is not the same as committing to unlimited weight gain.
Steps:
1. Define willingness as an open stance, not liking or wanting.
2. Ask the client to choose: quit while having these thoughts and feelings, or wait for them to disappear first.
3. Make the commitment out loud in the group.
Example language (illustrative): "Are you willing to have the worry about weight come along with you, if that's what it takes to be smoke-free?"
Watch for: reluctant compliance. Explore what makes willingness hard. Being working: the quit date is kept despite worry.

23. Mirror exposure with written thoughts (acceptance and defusion)

Purpose / when: group 6 (post-quit). Make contact with body-related thoughts in a supported way, then practise holding them lightly.
Consent and safety [synthesis, following standard exposure practice]:
- Explain the exercise in advance and make it optional.
- Get explicit consent, and allow the client to look at a body part rather than the whole body.
- Stop if distress becomes overwhelming.
- Contraindications include an active eating disorder, body dysmorphic disorder and recent trauma involving the body. In these cases, refer to or consult a specialist rather than running the exercise in a group.
Steps (as described in the paper):
1. In pairs, one partner stands before a full-length mirror and says their body thoughts aloud while the other writes them down.
2. Swap roles.
3. Shuffle the papers and read them aloud anonymously to the group.
4. Discuss how common and how "sticky" the thoughts are.
5. Participants tear up the papers and practise holding the thoughts "lightly" as a defusion exercise.
Example language (illustrative): "Just say what your mind tells you as you look. You're not agreeing with it, just reporting it."
Watch for: shame spikes, or urges to smoke after the session. Plan a coping step before people leave. Being working: lower emotional reactivity to the same thoughts, and the group normalising them.

24. Appetite awareness training

Purpose / when: groups 4–7. Spot eating that has replaced smoking, and learn to eat in response to physical hunger and fullness rather than external or emotional cues. Adapted from Craighead (2006).
Steps:
1. Teach the client to rate hunger and fullness before and after eating, using a simple scale in their own terms.
2. Monitor at home using a monitoring form, on paper or electronically. The DT-W team simplified the form after its pilot groups.
3. Review in group, looking for eating without physical hunger and eating past comfortable fullness.
4. Plan alternatives for the non-hungry eating episodes.
Example language (illustrative): "Before you reach for food this week, just check: is this stomach hunger, or is it the spot where the cigarette used to be?"
Watch for: the scale being used as a restriction rule ("I'm not allowed to eat unless..."). Being working: fewer substitute-eating episodes and no increase in urges.

25. Mindful eating exercise and practice

Purpose / when: groups 5–7. Slow down eating and notice hunger, taste and fullness, without distraction.
Steps:
1. In session, guide a slow eating exercise with a single small sweet, as described in the paper: look, smell, taste, notice the urge to hurry.
2. Debrief.
3. Assign one mindful meal or snack a day, with screens off.
Example language (illustrative): "Let it sit on your tongue and notice the urge to chew and move on. You don't have to act on it."
Watch for: distress in clients with binge eating, which needs gentle pacing. Being working: the client reports eating less automatically.

26. Committed action and daily commitments

Purpose / when: groups 4 and 8. Link quit goals to values and make daily commitments to healthy living. Participants choose their own goals, for example physical activity or fruit and vegetable intake.
Steps:
1. Restate the value (17).
2. Choose one or two small daily actions in its service.
3. Anticipate the thoughts that will show up, and plan to bring them along (20).
4. Review at the next session.
Example language (illustrative): "What's one thing you'll do each day this week that the non-smoking, healthy you would do?"
Watch for: actions chosen to burn calories rather than to serve values. Being working: actions are done on most days and abstinence holds.

4D. Variant C: personalised behavioural weight-gain prevention

No specific calorie, weight-loss or exercise targets are given here. The trials set these individually through a dietitian or nurse, and a therapist without dietetic training should refer for that part. [source: Lycett et al. 2010; SWISSS; NCSCT Briefing 9]

27. Hunger management plan (regular meals, healthy snacks, water)

Purpose / when: from quit day, in all variants. This is the "standard care" advice in the UK trials: hunger is linked to stronger urges, so prevent it rather than restrict.
Steps:
1. Map the client's usual eating day.
2. Plan regular meals.
3. Choose two or three satisfying, healthier snacks to keep on hand for craving times.
4. Encourage water.
5. Pair snacks with specific trigger times identified in the smoking log.
Example language (illustrative): "Let's make sure you're never running on empty in the first few weeks. When are you most likely to be hungry and craving at the same time?"
Watch for: grazing on high-energy foods as a cigarette substitute. Address it with 24/25 or step up to 29–31. Being working: hunger-linked urges are low and eating is predictable.

28. Periodic weighing with an early-action rule

Purpose / when: from quit day through maintenance. Catch rapid gain early without feeding distress.
Steps:
1. Agree how often to weigh. The NCSCT briefing advises periodic rather than very frequent weighing, and proposes a monthly rate of gain as the point to act; that cut-off is expert judgement, so check the current briefing.
2. Weigh in session, or have the client weigh at home on a set day.
3. Plot the results.
4. Agree in advance what happens if gain is rapid: step up to 29–31.
5. Ask the client to treat weighing day as a possible trigger (9).
Example language (illustrative): "Let's check your weight every so often, not every day. If it's climbing quickly, that's our signal to add more support, not a reason to smoke."
Watch for: distress or urges after weigh-ins. If so, reduce frequency or switch to blind weighing [synthesis]. Being working: the weighing schedule is kept and there are no weigh-in-triggered lapses.

29. Personalised assessment and about three agreed goals (IDAP)

Purpose / when: in the Lycett protocol, from about one week before quit day. Turn general advice into a few concrete, personally relevant behaviour goals. This is what separates effective from ineffective weight support in the Cochrane review.
Steps:
1. Assess current food choices, eating behaviour and activity. The trial used a structured questionnaire, the Health Choice Index; any structured diet and activity review serves the same function [synthesis].
2. Agree about three goals together, covering food choice, eating behaviour and activity.
3. Make each goal specific.
4. Review the goals regularly and replace any that have been met.
Example language (illustrative): "From what you've told me, the big ones seem to be the evening snacking and the fizzy drinks. Which two or three changes feel doable alongside stopping smoking?"
Watch for: goals that are really restrictive dieting (see 13). Being working: goals are met most weeks and abstinence is maintained.

30. Individual eating plan and agreed weight-gain limit (dietitian- or nurse-led)

Purpose / when: for clients who need more than goals: those who are overweight, at medical risk, or gaining rapidly. The NCSCT briefing describes a structured approach: agree an acceptable gain limit and an eating target with the client, then monitor against them. It also notes calorie restriction may cost abstinence, although there is no strong evidence that it does.
Steps:
1. Refer to, or work with, a dietitian or nurse. They set an individual energy prescription and a food-group plan; the trial supplied measuring cups for portions.
2. The therapist's role is to support adherence, link the plan to the quit plan, and monitor hunger and urges.
3. Review weight, hunger and urges together at each contact.
Example language (illustrative): "The dietitian has set out a plan that should stop you feeling starved. How are your hunger and cravings on it?"
Watch for: hunger and urges rising. If so, loosen the plan before risking the quit [synthesis]. Being working: gain stays inside the agreed limit with no rise in urges.

31. Referral to a structured community or commercial weight programme (SWISSS model)

Purpose / when: for clients with raised BMI who want weight support, starting near the quit date and lasting about 12 weeks. The programme is delivered by weight-programme staff, not the cessation advisor. In the UK, GP referral to weight or exercise programmes is another option.
Steps:
1. Discuss the options and the client's preferences.
2. Book a local group whose start date sits near quit day.
3. Keep usual cessation support running alongside.
4. Ask about the programme at each session (attendance, hunger, urges).
Example language (illustrative): "There's a local weight group you could start the same week you stop. They'll handle the food side and we'll keep focusing on the cigarettes."
Watch for: the programme's weight-loss framing pushing the client into restriction too early. Being working: the client attends, is abstinent, and gain is limited.

32. Very-low-calorie diet / meal replacement (specialist only)

Purpose / when: a research protocol for overweight smokers. Meal replacements start about a week before quit day and continue for the first weeks of abstinence, with intensive dietitian support and medical oversight, then move to a planned diet. Cochrane found less gain at end of treatment but not at 12 months. One study found better abstinence; in another, no one completed the diet. NCSCT notes few clients accept or keep to it.
Steps (therapist role only):
1. Do not initiate this yourself.
2. If a client asks about it, refer to a medically supervised service.
3. Support cessation work alongside. Contraindications and monitoring are for the medical team; the protocol checked ketosis weekly.
Example language (illustrative): "That's something that needs a doctor and dietitian to run. I can help you talk it through with them."
Watch for: self-started crash diets, which are a risk for relapse and for disordered eating [synthesis]. Being working: not applicable to the therapist alone.

4E. Variant D: adjuncts

33. Sequencing decision and the pre-quit weight-stability phase

Purpose / when: at intake. Decide whether weight work comes before, with, or after quitting.
Options:
- Quit first, weight later (NCSCT; UK trial control arms).
- Sequential: weight support begins after an initial cessation phase. In the Best Quit quitline trial, simultaneous delivery had lower abstinence than sequential or quit-only delivery, and neither approach reduced gain.
- Pre-quit stability (NCT03156660): about 8 weeks of keeping weight stable through self-weighing, step tracking and weekly feedback, then group cessation and monthly boosters. Its outcome was not found [uncertain].
- Concurrent intensive group work (Perkins; DT-W; Spring's in-person trials) [the Spring 2004 trial is not drawn on; uncertain].
Steps:
1. Present the options.
2. Choose based on setting, the client's capacity, and how much weight concern threatens quitting.
3. Document the choice.
4. Revisit it if quitting stalls.
Example language (illustrative): "We can tackle the cigarettes first and then the weight, or prepare the ground on weight first. Which feels more workable for you?"
Watch for: a pre-quit phase being used to keep postponing quitting. Set the quit date in advance. Being working: the quit date is kept.

34. Physical activity: supervised programme and acute exercise for cravings

Purpose / when: for sedentary clients who are willing. Commit to Quit added supervised vigorous exercise three times a week for 12 weeks to a weekly cessation group for women, which improved abstinence and roughly halved gain in that trial. The NCSCT briefing notes that exercise acutely reduces cravings, but supervised programmes have not been shown to improve long-term quit rates. Cochrane found a modest reduction in gain at 12 months (low certainty).
Steps:
1. Check medical readiness. Refer for clearance where cardiovascular or respiratory risk is present [synthesis, standard practice].
2. Agree an activity the client enjoys. Intensity and amount are set with an exercise professional; no targets are given here.
3. Schedule sessions and arrange supervision or a buddy.
4. Teach a short burst of activity, such as a brisk walk, as an "alternative" when cravings strike (5).
5. Track attendance. Commit to Quit adherers did better.
Example language (illustrative): "When a craving hits, a ten-minute brisk walk can take the edge off. Want to try that as your go-to this week?"
Watch for: compensatory over-exercise in weight-concerned clients [synthesis], and drop-off after week 4. Being working: regular attendance, and urges that ease after activity.

5. Handling problems

The primary sources say little about troubleshooting. Each item is marked by where it comes from.

Lapse or relapse after quit day. [source: Bloom et al. 2017; NCT03156660 protocol for structure; synthesis for detail]

Treat it as information.
Do a chain analysis of the lapse, asking specifically whether a weight thought, hunger or a weigh-in preceded it.
Re-commit to a new quit date quickly; avoid a long gap.
Check medication adherence.
If weight concern drove the lapse, add or intensify 12/14 (CBT) or 20/22 (ACT).
If hunger drove it, revisit 27 and loosen any restriction.

Client insists on dieting hard while quitting. [source: NCSCT Briefing 9; Perkins 2001 via NIDA; synthesis]

Validate the goal.
Explain the hunger–urge link.
Offer the structured alternative: a dietitian-set plan or referral (30/31) instead of self-imposed restriction.
Alternatively, offer a pre-quit stability phase (33) with a fixed quit date.
If the client goes ahead anyway, monitor urges weekly and agree a rule: if urges rise, the diet loosens first.

Client will accept no weight gain at all. [synthesis, drawing on Bush 2012 and Bloom 2017]

This is the core target of Variants A/B.
Run 12/14 or 19/22.
Show the spread of outcomes (2), which shows gain is not inevitable.
Offer close monitoring (28) as a safety net.
If the client still refuses, consider whether quitting now is right for them. A motivational, values-based discussion may be better than pressing for a quit date.

Rapid weight gain in the first months. [source: NCSCT Briefing 9]

Act early.
Review substitute eating (24).
Step up to personalised goals (29), a dietitian plan (30) or referral (31).
Ask the prescriber about medication options, including the second-line longer-term NRT the briefing describes.
Keep cessation support running.

Non-adherence to homework and monitoring. [source: Bloom et al. 2017 (most did not complete written homework; forms were simplified and completion praised); synthesis]

Shorten forms.
Offer app or phone entry.
Do monitoring together in session.
Praise partial completion.
Make one entry a day the minimum.

Overwhelm from two goals at once. [source: Bush et al. 2018; synthesis]

Simplify to "quit first".
Keep only the hunger plan (27) and periodic weighing (28).
Move structured weight work to after abstinence is stable.
In telephone or brief formats, default to sequential delivery.

Body-image distress or shame during exercises (mirror, weighing). [synthesis, following standard exposure practice]

Stop or slow the exercise.
Use grounding.
Offer a lower-intensity version (a body part, clothed, a brief look).
Debrief before the client leaves.
Plan a non-smoking coping step for the hours afterwards.
Do not repeat in a group if distress was severe; offer individual follow-up.

Suspected eating disorder. [synthesis]

Pause any eating plan or weighing.
Assess, or refer to an eating-disorder service.
Cessation support can continue, but weight-gain prevention components should be designed with the eating-disorder team.
Restrictive or VLCD approaches are contraindicated without specialist oversight.

Low mood or distress after quitting. [synthesis]

Withdrawal and the loss of smoking as a coping tool can lower mood.
Screen for depression.
Coordinate with the prescriber; bupropion has antidepressant properties, but that decision is the prescriber's.
Use distress-tolerance skills (21).
If there is any suicidal ideation, follow standard risk assessment and safety planning.

Ruptures over weight talk. [synthesis]

Clients may hear weight discussion as judgement, or hear the cessation focus as dismissing their fear.
Name the rupture.
Ask what felt off.
Restate that their fear is legitimate and that quitting is the shared goal.
Adjust the frequency of weighing or weight talk.
Keep language neutral (no "fat" or "obese" unless the client uses it).

Resistance to acceptance work ("I don't want to accept getting bigger"). [synthesis, ACT-consistent]

Clarify that willingness concerns thoughts and feelings, not a commitment to unlimited gain.
Return to the costs of control (19) and to values (17).
Pair the acceptance work with monitoring (28), so the client sees acceptance and action going together.

Programmes developed mostly for women. [synthesis] Perkins, Levine, DT-W and Commit to Quit enrolled women. For men, or for non-binary clients, keep the structure, adapt the examples, and explore weight concerns without assuming they look the same as in the trial populations.

Medical risk from gain (diabetes, cardiovascular disease, severe obesity). [source: NCSCT Briefing 9; synthesis]

Involve the medical team early.
Favour Variant C with a dietitian, plus pharmacotherapy.
Keep the message that quitting carries the larger health benefit.

Client wants to switch to e-cigarettes partly to avoid weight gain. [uncertain] The Cochrane review lists e-cigarettes among the cessation treatments assessed for weight effects, but the specific findings are not drawn on here. Refer to current national guidance and the prescriber or service.

Pregnancy or postpartum. [synthesis] Weight-gain prevention goals are inappropriate in pregnancy. Use specialist maternity smoking-cessation pathways.

Sources

Sources: