Introduction to Smoking Cessation

MSSM IIIEdward Anselm, M.D.

Assistant Professor of MedicineIcahn School of Medicine at Mount Sinai

Medical Director,Health Republic Insurance of New Jersey

EdwardAnselmMD.comeanselm@msn.com

Self Efficacy

• The perception that one can master a certain task or perform adequately in a given situation.

• Performance accomplishments• Vicarious experience• Verbal persuasion and social influence

New York City Trends

*Chart from NYC DOHMH available at www.nyc.gov

Adult Smoking in NYC Down Almost 27% Since 2002

15.8%15.8%

17.5%18.3%

21.5%

21.7%21.5%21.6%

19.2%

18.9%

16.9%

12

14

16

18

20

22

24

% o

f ad

ult

s

City and Statetax increases

Smoke-free workplaces

Free patchprograms

3-yr average 3-yr average 3-yr average

Hard-hitting media begins

16.4% decline since 2005

State tax increase

Federaltax increase

Over 75% of smokers recall having been advised to quit smoking in

2012Discussing Cessation Strategies

– Commercial Medicaid HMO PPO HMO

•2012 47.9 37.3 41.1 •2011 47.6 40.1 40.3 •2010 45.0 39.0 38.5 •2008 49.7 43.3 40.8 •2007 48.0 44.2 39.2 •2006 43.2 42.6 36.7 •2005 38.9 35.1 33.9 •2004 36.8 32.7 •2003 36.0 32.3

Discussing Cessation Medications– Commercial Medicaid HMO PPO HMO

•2012 52.9 44.6 45.8 •2011 53.1 47.9 44.3 •2010 52.4 47.2 42.7 •2008 54.4 50.9 40.6 •2007 50.9 49.6 38.7 •2006 43.9 43.8 35.1 •2005 39.4 36.7 31.8 •2004 37.8 31.3 •2003 37.6 31.5

Targeted Marketing

• Women

• Young People

• Racial and Ethnic Minorities

• Lesbian/Gay/Bisexual/Transgender

Role of the Physician

Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up

The Role of the Physican

Five “A”sAsk about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up

•Every patient quitting cigarettes should be offered a medication

Two “A”s + RAsk about smokingAdvise tobacco users to

quitRefer to cessation services

Five “R”sRelevanceRisksRewardsRoadblocksRepetition

Effect of General Practitioners’ Advice Against Smoking

Russell, MAH et al, , BMJ 1979 2, 231-5

02468

101214161820

Group 1 Group 2 Group 3 Group 4

one year

one month

Ask about smoking

Ask about smoking at every visit.

Do you smoke?How much do you smoke each day?What brand do you smoke?Have you ever smoked other

brands?

Vital Signs Stamp

VITAL SIGNSVITAL SIGNS

Pulse:Pulse:

Temperature:Temperature:

Respiratory Rate:Respiratory Rate:

(circle one)(circle one)

CurrentCurrent FormerFormer Never NeverTobacco Use:Tobacco Use:

Blood Pressure:Blood Pressure:

Weight:Weight:

Advise tobacco users to quit

“ I want you to quit smoking.”

“It is important for you to quit smoking.”

“Tell me about your previous attempts to quit.”

“Why did you go back to smoking?”

Assess readiness to quit

Do you believe you will be able to quit smoking in the next six months?

Do you believe you will be able to quit smoking in the next month?

Would you like to set a date?

Assist with a plan for quitting

Contracting for Behavior Change

Setting a quit date

Use of printed materials

Set expectations

Follow-up visit/phone call

Use of medication

Use of support groups

• A CONTRACT TO QUIT SMOKING

•   

• AGREE TO QUIT SMOKING ON _________________

•  

• I WANT TO QUIT SMOKING BECAUSE___________________

•  

• MY REWARDS WILL BE __________________________

•  

COST OF SMOKING in NYC

Cost of a pack $10.25 Packs Number of Cost per day per month per year

per cigarettes

day per day

0.5 10 $ 5.13 $153.75 $ 1,870.63

1 20 $10.25 $307.50 $ 3,741.25

1.5 30 $15.38 $461.25 $ 5,611.88

2 40 $20.50 $615.00 $ 7,482.50

3 60 $30.75 $922.50 $11,223.75

Arrange follow-up

Telephone Office visitFind out what went wrongAsk patient to recommit to plan

The Impact of Physician Advice to Quit Smoking

Simple advice 5%

Advice plus follow-up 10%

% of all smokers abstinent at one year after intervention

Enhancing the Impact of Simple Advice and Follow-up

Medication doubles or triples the impact of any intervention

Group support doubles the impact of any intervention

Role of the Physician

Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up

The Behavior of Smoking I

Early Experimentation

Brand Identification

Regular SmokersChippers

Light Smokers

Heavy Smokers

Interest in quitting

The Behavior of Smoking II

Nicotine is an addictive drug

Nicotine delivery to brain in eight seconds

Most smokers maintain a steady level of nicotine

10-12 puffs per cigarette

20 cigarettes per day (200 puffs)

7300 cigarettes per year (73,000 puffs)

The Behavior of Smoking III

Oft repeated habit

Social situations

Stress management

Associated with food, alcohol

Low awareness of risk

Fear of failure

Episodic Mood Management

Nicotine Withdrawal

Anxiety

irritability

anger

restlessness

difficulty concentrating

The Natural History of Smoking Cessation

50 Million former smokers5-8 efforts to quit smokingEach effort resulted in longer

periods of abstinence from smoking

Process over several years

Methods of Smoking Cessation

Self Help

Physician Advice

Counseling

Social Support

Telephonic Support and Advice

Smoking Cessation Classes

Medication

Hypnosis/Acupuncture

Smoking Cessation and Weight Gain

Smokers weigh less than non-smokers

5-10 pound gain, on average

Less initial weight gain with use of medication

Why do people relapse?

Nicotine withdrawalAlcoholStressSocial situation

What to do if your patient relapses

Find out why

More intensive treatment

Referral for intensive program

Psychiatric evaluation

Use of Medication

Nicotine PatchNicotine Gum, Nasal SprayNicotine Lozenge, InhalerBuproprion, and other AntidepressantsCombination TherapyVarenicline (Chantix)RimonibantNicotine Vaccine

Role of the Physician

Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up

JAMA 2000 Nov 22-29; 284 (20): 2606-10

Smoking and Mental Illness

23

3541 39

55 59

4237

31

0

10

20

30

40

50

60

CurrentSmoking Rates

LifetimeSmoking Rates

Quit Rates

No Mental IlnessAnytime in LifetimeCurrent

Tobacco Use and Mental Health

• Nicotine and self medication

• Episodic mood management

• Depression

• Substance abuse

• Anxiety Disorders

• OCD, ADD

• Schizophrenia

Electronic Nicotine Delivery Systems: E-Cigarettes

• Regulatory Perspectives– Variation in products– Safety to smokers– Safety to bystanders– Use by children; flavored – Efficacy in smoking cessation

• Alternative to smoking

• Aid in behavior change

Harm Reduction

• Low Tar and Nicotine Cigarettes

• NICE Tobacco Harm Reduction Guideline

• Identification and treatment of persons who are self-medicating with nicotine

• Structured Quit attempts

• Diagnosis and Treatment of Depression

Self Efficacy

• The perception that one can master a certain task or perform adequately in a given situation.

• Performance accomplishments• Vicarious experience• Verbal persuasion and social influence