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 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

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

Motivating Patients to QuitSome 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

• 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?

1. Do you smoke?2. Are you interested in quitting? - stages of

changeIf no, encourage thinking about quittingIf yes, proceed –

3. How much do you smoke?4. How soon after waking do you smoke?5. Have you tried to quit before?6. In what situations do you enjoy smoking?7. Do others in the home smoke?8. Have you had problems with alcohol, drugs?9. Have you had medical or psychiatric problems?

“ASK”

dependence

antecedents

Impact treat.

Variables Associated With Lower Cessation Rates*

Stressful life circumstances and/or recent major life change (eg, divorce, job change)

High stress level

Other smokers in the home or workplaceEnvironmental risks

Smoker reports perceived inability to quitLow self-efficacy

Smoker reports not being ready to quitLow readiness to change

Smoker reports low motivation to quitLow motivation

Depression, schizophrenia, alcoholism, other chemical dependency

Psychiatric Comorbidity

Smoker reports severe withdrawal during previous quit attempts

High nicotine dependence

ExamplesVariable

“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 & expectations2. Behavioral counseling (essential)

a. Heighten motivationb. Set quit datec. Ask about and deal with anticipated

difficultiesd. 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

Women did worse than men on gum and tended to do worse on patch and spray, but women better than men on inhaler.

West et al. 2001 open label

0

5

10

15

20

25

30

35

Gum Patch Spray Inhaler

NRT method

15-w

eek

abst

inen

ce (

%)

Men

Women

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