SMOKING cessation Robert Mallin MD Department Family Medicine

SMOKING cessation Robert Mallin, MD Department Family Medicine Medical University of South Carolina

General Reading Recommendations • 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 -3254.

General Reading Recommendations • Mallin R, Management of Smoking Cessation: Integration of Behavior and Pharmacotherapy. American Family Physician 65: 6 1107 -14 2002

Module 1 • EPIDEMIOLOGY

Module 1 Epidemiology • • • 23. 5% of adults smoke 33% young adults (18 -25) smoke 70% smokers want to quit 7% will be successful quitting on their own 35% can quit with treatment

Module 1 Epidemiology • • • Annual deaths attributed to smoking…. 440, 000 Cost of smoking annually… $150 billion Avg adult male and female lost years of life 13. 2 Men 14. 5 Women

Module 1 Illness related to smoking • Cardiovascular Disease Sudden death Acute myocardial infarction Unstable angina Stroke Peripheral arterial occlusive disease Aortic aneurysm • Pulmonary Disease Lung cancer Chronic bronchitis Emphysema Asthma Increased susceptibility to pneumonia Increased morbidity from viral respiratory infection

Module 1 Illness related to smoking • Gastrointestinal Disease Peptic ulcer Esophageal reflux • Reproductive Disturbances Reduced fertility Premature birth Lower birth weight Spontaneous abortion Abruptio placentae Premature rupture of membranes Increased perinatal mortality

Module 1 Illness related to smoking • Oral Disease (Smokeless Tobacco) Oral cancer Leukoplakia Gingivitis Gingival recession Tooth staining • Other Earlier menopause Osteoporosis Cataract Premature skin wrinkling Aggravation of hypothyroidism Altered drug metabolism or effects

Module 1 Cancers associated with smoking • Lung • Kidney • Larynx • Stomach • Oral cavity • Leukemia • Esophagus • Cervix • Pancreas • Bladder

Review Questions Module 1 Epidemiology • Which of the following reflects the percentage of smokers in the 18 -25 age group? • A. 23% • B. 9% • C. 33% • D. 70%

Review Questions Module 1 Epidemiology • • • What percent of smokers would like to quit? A. 10% B. 35% C. 50% D. 70%

Review Questions Module 1 Epidemiology • Which of the following cancers are associated with smoking? • A. Bladder • B. Colon • C. Liver • D. All of the above

Module 2 • 5 A’s of Smoking Cessation

Module 2 Agency for Healthcare Research and Quality Clinical Guidelines • Three truths about tobacco – 1. All tobacco products exact devastating costs on the nation’s health and welfare. – 2. For most users tobacco use results in drug dependence comparable to that of opiates, amphetamines and cocaine. – 3. Chronic tobacco use warrants repeated clinical intervention as do other addictions.

Module 2 Empirical Basis for Guidelines • Consensus panel reviewed over 300 RCT of tobacco-use cessation interventions came to the following conclusions; – Effective smoking cessation treatments are available, and every patient who smokes should be offered one or more of these treatments – It is essential that clinicians determine and document the tobacco-use status of every patient treated in a health care setting.

Module 2 Empirical Basis for Guidelines – Brief cessation treatments are effective, and at least a minimal intervention should be provided to every patient who uses tobacco. – A dose-response relation exists between the intensity and duration of a treatment and its effectiveness. In general, the more intense the treatment, the more effective it is in producing long-term abstinence from tobacco

Module 2 Empirical Basis for Guidelines – Three treatment elements, in particular, are effective, and one or more of these elements should be included in smoking cessation treatment • Nicotine replacement therapy (nicotine patches or gum) • Social support (clinician-provided encouragement and assistance) • Skills training and problem solving (techniques on achieving and maintaining abstinence)

Module 2 Empirical Basis for Guidelines – Effective reduction of tobacco use requires that health care systems make institutional changes that result in systematic identification of, and intervention with, all tobacco users at every visit.

Module 2 Primary Care Interventions • 5 A’s of smoking cessation – 1. Ask the patient if he or she uses tobacco – 2. Advise him or her to quit – 3. Assess willingness to make a quit attempt – 4. Assist those willing to quit – 5. Arrange for follow-up contact to prevent relapse

Review Questions Module 2 • Which of the following is true? • A. Smoking is a good example of physical dependence without addiction. • B. Smokers should be encouraged to quit, but treatment is rarely effective. • C. Nicotine is not an addictive substance • D. Longer and more intense treatment is more effective than shorter, less intense treatment for smoking cessation.

Review Questions Module 2 • The first step in the 5 A’s of Smoking cessation is which of the following? • • A. Assess willingness to make a quit attempt. B. Advise him or her to quit C. Ask the patient if he or she uses tobacco D. Assist those willing to quit

Module 3 • Assess –Tobacco Use

Module 3 Assess Tobacco Use • Ask if patient uses tobacco • Tobacco use as a Vital Sign – One of the most effective ways to Ask patients about their tobacco use if to include it in the Vital sign section of the chart. – When office personnel record the patient’s tobacco use at each visit, the health care provider is three times more likely to address the issue with the patient.

Module 3 Assess Tobacco Use • If your patient smokes or uses tobacco, take a tobacco use history. • How much do you smoke? • When did you begin smoking? • Have you ever quit smoking? • If so, how long were you abstinent? • What happened to make you start smoking again?

Module 3 Assess Tobacco Use • Would you like to stop smoking? • Do you think you would like to make a quit attempt in the next few weeks or months? • Do you have any questions about smoking cessation?

Module 3 Assess Tobacco Use • Smoking Patients should be placed in one of three categories. • Those unwilling to make a quit attempt in the near future. • Those willing to make a quit attempt in the near future • Those who have recently quit.

Review Questions Module 3 • Regarding the smoking history which of the following is true? • A. Most physicians ask their patients about smoking. • B. The percentage of health care providers that discuss smoking with their patients is increased by using smoking as a vital sign. • C. The best way to approach a patient about their smoking is to say “ You don’t smoke do you? • D. There is little use in discussing smoking with patients because very few patients want to quit.

Module 4 • Advise –Your patient to quit

Advise him or her to quit • In a clear, strong, and personalized manner, urge every tobacco user to quit. – Clear—"I think it is important for you to quit smoking now and I can help you. ” "Cutting down while you are ill is not enough. " – Strong—"As your doctor, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you. "

Advise him or her to quit • In a clear, strong, and personalized manner, urge every tobacco user to quit. – Personalized—Tie tobacco use to current health/ illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household – “Your asthma will improve when you stop smoking”

Assess willingness to make a quit attempt • Ask every tobacco user if he or she is willing to make a quit attempt at this time (e. g. , within the next 30 days). – Current users who are willing to quit – Current users unwilling to quit at this time

Review Questions Module 4 • Which of the following is the most appropriate message to give your patient about smoking? • A. “You know you should quit smoking, don’t you? ” • B. “If you cannot quit smoking, I think you should find another doctor. ” • C. “You will certainly die if you continue to smoke” • D. “ Mr. Jones, as your doctor, I have to tell you that the most important action you can take to improve your health would be to quit smoking. ”

Module 5 • Stages of Change

Module 5 Reading • A 'stages of change' approach to helping patients change behavior. Zimmerman GL - Am Fam Physician - 1 Mar-2000; 61(5): 1409 -16

Stages of Change • Prochaska and Di. Clemente used smoking cessation as the model for the development of the stages of change. This model may be used to assess the readiness of your patient to change and can guide you in which techniques of motivational interviewing (discussed later) will be most effective in helping your patient move closer to their goal.

Stages of Change • Precontemplative – “I don’t have a problem. ” These are patient’s who really do not think that smoking is a problem for them. They are not considering quitting • Contemplative – “ I think I may need to quit, but I’m not ready. ” These patients recognize that they need to quit smoking and may even want to quit but are currently not ready to commit to giving it a try.

Stages of Change • Preparation – “I want to quit. ” This is a patient who is ready to commit to making a quit attempt. • Action – “I stopped smoking today. ” • Maintenance/Relapse – Refers the continuation of the behavior change or the relapse to old behavior (smoking) after the change has been made.

Stages of Change • Remember, patients predictably go through these stages when they make any significant change. They cannot “jump” stages. Consequently, expecting a patient to move from precontemplation to action without going through contemplation and preparation is unrealistic. So your goal for the patient in precontemplation should be for them to get to contemplation. This has considerable importance as we discuss motivational interviewing techniques

Review Questions Module 5 • Choose the appropriate stage of change for the following statement. • “Doc, this scare about smoking is a government conspiracy to get the tobacco companies. ” – A. Precontemplation – B. Contemplation – C. Preparation – D. Action – E. Maintenance

Review Questions Module 5 • Choose the appropriate stage of change for the following statement. • “I set my quit date for three weeks from tomorrow. ” – A. Precontemplation – B. Contemplation – C. Preparation – D. Action – E. Maintenance

Review Questions Module 5 • Choose the appropriate stage of change for the following statement. • “I am worried about my smoking, but I just don’t seem to be able to quit. ” – A. Precontemplation – B. Contemplation – C. Preparation – D. Action – E. Maintenance

Review Questions Module 5 • Choose the appropriate stage of change for the following statement. • “I stopped smoking over a year ago. ” – A. Precontemplation – B. Contemplation – C. Preparation – D. Action – E. Maintenance

Module 6 • Motivational Interviewing –For those unwilling to make a quit attempt at this time

Reading for Module 6 • Motivational interviewing in health care settings: Opportunities and limitations, Karen M. Emmons and Stephen Rollnick American Journal of Preventive Medicine Volume 20, Issue 1 , January 2001, Pages 68 -74

Motivational Interviewing • Motivational interviewing as developed by Miller and Rollnick is a technique to help patients change behavior. In the context of this module you will learn suggestions that will help your patients move to the next stage of change in.

Motivational Interviewing • General Principles • Expressing empathy by the use of reflective listening. • Developing discrepancy between the patients goals and current behavior by the use of reflective listening and objective feedback. • Avoiding arguments by assuming that the patient is responsible for the decision to change. • Rolling with resistance rather than confronting or opposing it. • Supporting self efficacy and optimism for change.

Motivational Interviewing • General Principles Examples • Expressing empathy by the use of reflective listening. – “Stopping smoking is difficult, I can see that you have tried hard to quit. ” • Developing discrepancy between the patients goals and current behavior by the use of reflective listening and objective feedback. – “I heard you say that you are concerned for your health, and that you know that smoking is harming your health. I wonder how it makes you feel to be continuing to smoke under these conditions? ”

Motivational Interviewing • Avoiding arguments by assuming that the patient is responsible for the decision to change. – “I’d really like to help you, but only you can decide of you want to quit. ” • Rolling with resistance rather than confronting or opposing it. – “It sounds like you are not ready to consider quitting right now. Would it be ok if we continued this conversation another time? ” • Supporting self efficacy and optimism for change. – Stopping smoking is really hard, but I am certain that you can be successful. ”

Motivational Interviewing for the Precontemplative/Contemplative • 5 Rs – Relevance – Risks – Rewards – Roadblocks – Repitition

Motivational Interviewing for the Pre-contemplative/Contemplative • Relevance – Encourage the patient to indicate why quitting is personally relevant to their disease status or risk factors. – “Your family history and hypertension increase your risk for cardiovascular disease. Stopping smoking would improve your risk greatly. ”

Motivational Interviewing for the Pre-contemplative/Contemplative • Risks – Ask the patient to identify potential negative effects of smoking • Acute risks: SOB, exacerbation of Asthma, cough • Long term risks: MI, CVA, cancer, lung, bladder, cervix, COPD, costs for extended care • Environmental risks: Increased risk of lung cancer, in non-smokers exposed, low birth weight, increased respiratory infections in children

Motivational Interviewing for the Pre-contemplative/Contemplative • Rewards – Ask the patient to identify potential benefits of stopping smoking that seem most relevant to the patient • • • improved smell and taste, saved money improved conditioning reduced skin damage healthier children

Motivational Interviewing for the Pre-contemplative/Contemplative • Roadblocks – Ask the patient to identify potential barriers • • • lack of support depression loss of enjoyment of tobacco weight gain cost of pharmacotherapy

Motivational Interviewing for the Pre-contemplative/Contemplative • Repetition – repeat motivational interviewing each time you see patient. – Failed attempts to quit should be met with the understanding that most people require multiple attempts to quit – “You will almost certainly be successful if you keep trying. ”

Review Questions Module 6 • Which of the following statements reflect empathy on the part of the interviewer? • A. “I heard you say that you are concerned for your health, and that you know that smoking is harming your health. I wonder how it makes you feel to be continuing to smoke under these conditions? ” • B. “I’d really like to help you, but only you can decide of you want to quit. ” • C. “Stopping smoking is really hard, but I am certain that you can be successful. ” • D. “Stopping smoking is difficult, I can see that you have tried hard to quit. ”

Review Questions Module 6 • Which of the following might be a roadblock to a patient making the necessary changes to quit smoking? • A. Lack of support • B. Other Smokers • C. Drinking alcohol • D. Improved smell and taste

Review Questions Module 6 • Choose the best response to the following statement made by your patient. . ”Doc, I just don’t want to talk about my smoking today. ” • A. “Mr. Smith I must tell you that you simply have to quit smoking” • B. “Why not? Are you afraid of something? ” • C. “OK, can we come back to this another time then? ” • D. “Can you tell me what smoking is doing to your health? ”

Module 7 • Assist –Those willing to attempt to quit

Module 7 • Finally! Your patient tells you they are ready to make a quit attempt. What now? Write a Rx for Zyban or the patch and tell them good luck? Hardly! Now the real work begins.

Motivational Interviewing for Preparation/Action Stages • Identification of triggers – Other smokers – Drinking alcohol – Experiencing urges – Stressful situations

Motivational Interviewing for Preparation/Action Stages • Identification of Coping Strategies – Anticipate, and avoid temptation. – Cognitive strategies reduce stress and negative mood. – Lifestyle changes that improve quality of life. – Learning cognitive and behavioral strategies to deal with urges to smoke.

Motivational Interviewing for Preparation/Action Stages • Provide basic information about smoking and successful quitting – Any smoking will likely result in relapse – Withdrawal typically peaks between 1 -3 weeks of smoking cessation – Withdrawal symptoms include depressed mood, irritability, urges to smoke, and difficulty concentrating.

Motivational Interviewing for Preparation/Action Stages • Intratreatment Support – Encourage the patient to quit • Effective treatment for nicotine dependence is available. • Half of the people who have ever smoked have quit. • “You can quit smoking, I am certain of it. ”

Motivational Interviewing for Preparation/Action Stages • Intratreatment Support – Communicate caring and concern • Ask patient how they feel about quitting. • Directly express concern and willingness to help. • Be open to the patients fears about quitting, difficulties experienced, and ambivalent feelings.

Motivational Interviewing for Preparation/Action Stages • Intratreatment Support – Encourage the patient to talk about the quitting process • Ask about – – Reasons patient wants to quit Concerns or worries about quitting Success patient has achieved Difficulties encountered while quitting

Motivational Interviewing for Preparation/Action Stages • Extra treatment support – Train Patient in support solicitation skills • Videos • Practice asking family friends, co-workers for support • Help patient to establish smoke free home

Motivational Interviewing for Preparation/Action Stages • Extra treatment support – Prompt support seeking • Help patient identify support • Remind patient to call supportive others • Community resources of support

Motivational Interviewing for Preparation/Action Stages • Extra treatment support – Clinician arranges outside support • Mail letters to supportive others • Call supportive others • Assign patients to be “buddies” to one another

Specific Recommendations in Preparation for Smoking Cessation • • • Set a quit date. Read educational materials Make a list of triggers Make a list of coping strategies Make a list of support network Remove all smoking paraphernalia from home, car office. • Be sure to understand the appropriate use of pharmacological aids

Pharmacotherapy for Smoking Cessation • Two Goals: • 1. Reduce the symptoms of nicotine withdrawal. (physical dependence) • 2. Reduce craving for nicotine. (addiction) • Nicotine replacement therapy addresses the first goal • Bupropion addresses both goals. • Either nicotine replacement, or bupropion increases quit rates from 7% (no therapy) to about 30% (with therapy and social support). • There is suggestive evidence that using both bupropion and nicotine replacement is somewhat better than either one

Pharmacotherapy for Preparation/Action Stages • Who should get pharmacotherapy? – All smokers except • • smoking less than 10 cigarettes/d Pregnant Breast feeding Adolescent

Pharmacotherapy for Preparation/Action Stages • Which treatments are considered first line, FDA approved? – Bupropion – Nicotine gum – Nicotine inhaler – Nicotine nasal spray – Nicotine patches

Pharmacotherapy for Preparation/Action Stages • Bupropion (sustained release) – Precautions/Contraindications • Seizure, eating disorders – Adverse effects • Insomnia, Dry mouth – Dose • 150 mg QD X 3 then 150 mg BID Begin 2 wks prior to quit date

Pharmacotherapy for Preparation/Action Stages • Bupropion (sustained release) – Duration • 7 -12 wks up to 6 mos. – Cost/day • $3. 30/day

Pharmacotherapy for Preparation/Action Stages • Nicotine Gum – Adverse effects • Mouth soreness, dyspepsia – Dosage • 1 -24 cig. /d 2 mg up to 24/d • >25 cig. /d 4 mg up to 24/d – Duration • up to 12 weeks – Cost/day • about $7/d for 10 pieces

Pharmacotherapy for Preparation/Action Stages • Nicotine inhaler – Adverse effects • local irritation mouth and throat – Dose • 6 -16 cartridges/d – Duration • up to 6 months – Cost/day • about $11. 00/10 cartridges

Pharmacotherapy for Preparation/Action Stages • Nicotine nasal spray – Adverse effects • nasal irritation – Dose • 8 -40 doses/d – Duration • 3 -6 mos – Cost/day • $5. 40/12 doses

Pharmacotherapy for Preparation/Action Stages • Nicotine Patch – Adverse effects • Local skin reactions, insomnia – Dose • 21 mg, 14 mg, 7 mg – Duration • 4 wks (21 mg) 2 wks (14 mg) 2 wks 7 mg – Cost/day • $4. 22

Pharmacotherapy for Preparation/Action Stages • All of the nicotine replacement therapies appear to be equally efficacious. Consequently it is best to allow the patient to choose which type of nicotine delivery system they prefer. • More than one system can be used, ie. gum in addition to the patch. If the patient is perceiving withdrawal symptoms on the patch alone.

Pharmacotherapy for Preparation/Action Stages • Second line medications – Clonidine – Adverse reactions: dry mouth drowsiness, dizziness sedation – Dose: 0. 15 -0. 75 mg/d – Duration: 3 -10 wks – Cost/day: $0. 25

Pharmacotherapy for Preparation/Action Stages • Second line Medications – Nortryptaline – Precautions: risk of arrythmias – Adverse effects: sedation dry mouth – Dose: 75 -100 mg /d – Duration: 12 wks – Cost: $0. 75/d

Choosing Nicotine Replacement Dose • Modified Fagerstrom Score • 1. How many cigarettes do you smoke daily? – 0 -10 0 points – 10 -20 1 point – 20+ 2 points

Choosing Nicotine Replacement Dose • 2. How soon after waking do you smoke? – 1 hour + – 30 m-1 hr – < 30 m 0 points 1 point 2 points

Choosing Nicotine Replacement Dose • 3. How long can you comfortably go w/o smoking? – >2 hrs 0 points – 1 -2 hrs 1 point – <1 hr 2 points

Choosing Nicotine Replacement Dose • • • Score 0 -1 points 1 -2 points 3 -4 points >4 points None (prn nicorette) 7 mg patch 14 mg patch 21 mg patch

Review Questions Module 7 • Which of the following are symptoms of nicotine withdrawal? • A. Tremor • B. Piloerection (gooseflesh) • C. Difficulty concentrating • D. All of the above

Review Questions Module 7 • Nicotine withdrawal typically peaks at which of the following time periods? • A. 1 -3 days • B. 6 -8 weeks • C. 2 -3 months • D. 1 -3 weeks

Review Questions Module 7 • Your patient identifies after meals as a potential trigger. He likes to have a cigarette after his meals. Which of the following coping strategies would be best to recommend? • A. Think about something other than smoking after meals. • B. Plan a different activity after meals, (go for a walk). • C. Take a tranquilizer during the meal. • D. Have a couple of beers instead.

Review Questions Module 7 • Your patient has a 30 pk year history of smoking, and smokes 2 ppd. He reports smoking within 5 min of waking, and rarely goes for more than 2 hours without a cigarette. Which dose of nicotine patch would you choose for him to use in attempting to quit? • A. None (prn nicorette) • B. 7 mg patch • C. 14 mg patch • D. 21 mg patch

Review Questions Module 7 • Mr. Smith has a history of smoking 2. 5 ppd for over 30 years. He has a past medical history of heart disease (MI 2 yrs ago), HTN, and DMII, epilepsy. Which of the following pharmacologic regimens would be most appropriate for him in attempting to quit smoking? • A. No medication would be safe for this patient. • B. Nicotine patch • C. Clonidine • D. Bupropion and nicotine patch • E. Bupropion alone

Module 8 • Arrange –for follow-up

Module 8 • Just as pharmacotherapy without appropriate preparation is not effective for smoking cessation, neglecting to have close contact during the action stage is likely to result in relapse. • There is a relationship between the frequency, intensity and duration of the contact and success in abstinence.

Module 8 • Considerations in follow-up care: • Daily contact in person or by phone is best for the first few weeks – Discuss level of abstinence – Discuss side effects from medication – Discuss breakthrough withdrawal – Discuss feelings regarding quit attempt – Discuss triggers and coping responses

Module 8 • • Relapse Common, given the best practice quit rate of about 35% Empathetic, optimistic support. “I know you have tried hard to quit, and I am certain if you continue to try, you will eventually become successful. ” • “When you are ready to try again, we will take a look at what went wrong this time and develop a plan to consider those problems. ”

Summary • Ask: Find out who smokes. • Advise: Tell them they need to quit. • Assess: Who is ready to quit. – Determine their readiness for change – Use motivational interviewing skills • Assist: those willing to quit – Education about smoking, quitting ext. – Identification of triggers Development of coping strategies – Development of support network • Arrange: follow-up – anticipate relapse