STAGES OF CHANGE
Precontemplation Contemplation Action Maintenance
Relapse
Not yet considering quitting Thinking about quitting Making a quit attempt Remaining a nonsmoker
Starting to smoke again
Implementing Smoking Cessation Strategies
The 4 A’s – for patients willing to make a quit attempt now •ASK about tobacco use at every encounter •ADVISE all smokers to quit •ASSIST the patient in quitting •ARRANGE for a follow-up
The 4 R’s to enhance motivation – for patients unwilling to quit at this time • RELEVANCE: Tailor advice and discussion to each patient • RISKS: Outline risks of continued smoking • REWARDS: Outline benefits of quitting • REPETITION: Reinforce motivational message at every visit
Some Benefits of Smoking Cessation
• Improved health • Food tastes better • Improved sense of smell • Save money • Feel better about yourself • Home, car, breath will smell better • Can stop worrying about quitting
Motivating Patients to Quit
• Set a good example for children • Healthier babies and children • Not worry about exposing others to smoke • Feel better physically • Freedom from addiction • Perform better in sports
What about cutting down?
What about switching to lights?
“ASK”
1. 2. Do you smoke? Are you interested in quitting? - stages of change If no, encourage thinking about quitting If yes, proceed –
3. 4. 5. 6. 7. 8. 9.
How much do you smoke? depende How soon after waking do you smoke? Have you tried to quit before? In what situations do you enjoy smoking? antece Do others in the home smoke? I Have you had problems with alcohol, drugs? t Have you had medical or psychiatric problems?
Variables Associated With Lower Cessation Rates*
Variable High nicotine dependence Psychiatric Comorbidity Low motivation Low readiness to change Low self-efficacy
Examples
Smoker reports severe withdrawal during previous quit attempts
Depression, schizophrenia, alcoholism, other chemical dependency Smoker reports low motivation to quit
Smoker reports not being ready to quit
Smoker reports perceived inability to quit
Environmental risks High stress level
Other smokers in the home or workplace
Stressful life circumstances and/or recent major life change (eg, divorce, job change)
“ADVISE”
•All smokers should be strongly advised to quit. •Even just 5 mins of strong advice to quit from a doctor can increase quitting.
“ASSIST”
1. Medication (NRT, Zyban) : Give clear instructions & expectations 2. Behavioral counseling (essential) a. Heighten motivation b. Set quit date c. Ask about and deal with anticipated difficulties d. Teach coping strategies; e.g., avoid smoking locations for awhile, use substitutes (sugarless candy), keep busy e. Self-reward for maintaining cessation (e.g. social support)
Nicotine Withdrawal Symptoms
Withdrawal peaks in 2 days and lasts up to 1-2 weeks (on average) • • • • • • • Depressed mood, sadness Insomnia Irritability, frustration, anger Anxiety Impaired concentration Restlessness Increased appetite
ZybanR (bupropion) SR
•First non-nicotine medication approved by FDA for smoking cessation. Originally approved by FDA as anti-depressant (WelbutrinR). •Requires doctor’s prescription and medical monitoring •Doubles quit rates vs placebo.
Nicotine Replacement Therapy
• Blunts withdrawal symptoms and reduces cravings • Recommended for all smokers (except in special circumstances) • Safe
– Nicotine is the psychoactive ingredient of tobacco that leads to addiction. – But, it is the 4000 other compounds in tobacco smoke that cause most of the disease risk
•Formulations:
gum (2, 4 mg; NicoretteR)--available OTC patch (up to 21 mg; e.g. NicodermR) --available OTC nasal spray (NicotrolR) “inhaler” lozenge
West et al. 2001 open label
35
15-week abstinence (%)
30 25 20 15 10 5 0 Gum Patch Spray Inhaler NRT method Men Women
Women did worse than men on gum and tended to do worse on patch and spray, but women better than men on inhaler.
INSERT FIG SHOWING KINETICS OF CIGS AND NRT, to illustrate why NRT might not work that well
Antecedents and Consequences
Antecedents
• • • • • Persistent salience of environmental cues Expectancy of positive effects of smoking Modeling of smoking (being around other smokers) Easy availability of cigarettes Reduced availability of alternative reinforcers.
Consequences
• Experiencing smoking effects (priming) • Secondary reinforcement (e.g. approval from other smokers, such as friends or spouse who smoke)
“ARRANGE” Follow-Up
Schedule follow-up within one week Follow up again within first month if possible Set additional follow-up as necessary Congratulate success during all contacts If smoking has occurred, review circumstances and encourage another try • Identify problems encountered and anticipate challenges to a new quit attempt • Assess use/misuse of nicotine replacement therapy or other medication • Consider referral • • • • •
Cost Effectiveness of Smoking Cessation Programs
Similar to treatment of mild or moderate hypertension, or hypercholesterolemia* Estimated cost per year of life saved**
$2,000 traditional smoking cessation program $50,000 mammographic screening for breast cancer *Cummings et. al. JAMA. 1989;261:75-79. **Marwick. JAMA. 1996;276:1291