STAGES OF CHANGE

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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

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Implementing Smoking Cessation Strategies

• The 4 As 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 Rs 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

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Motivating Patients to QuitSome Benefits of
Smoking Cessation

• 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

• 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

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What about cutting down?
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What about switching to lights?
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ASK

• Do you smoke?
• Are you interested in quitting? - stages of
  change
• If no, encourage thinking about quitting
• If 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?

dependence
antecedents
Impact treat.
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Variables Associated With Lower Cessation Rates
Examples
Variable
High nicotine dependence
Smoker reports severe withdrawal during previous
quit attempts
Psychiatric Comorbidity
Depression, schizophrenia, alcoholism, other
chemical dependency
Smoker reports low motivation to quit
Low motivation
Low readiness to change
Smoker reports not being ready to quit
Smoker reports perceived inability to quit
Low self-efficacy
Other smokers in the home or workplace
Environmental risks
Stressful life circumstances and/or recent major
life change (eg, divorce, job change)
High stress level
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ADVISE

• All smokers should be strongly advised to quit.
• Even just 5 mins of strong advice to quit from a
  doctor can increase quitting.

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ASSIST

• Medication (NRT, Zyban) Give clear
  instructions expectations
• Behavioral counseling (essential)
• Heighten motivation
• Set quit date
• Ask about and deal with anticipated difficulties
• 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)

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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

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ZybanR (bupropion) SR

• First non-nicotine medication approved by FDA for
  smoking cessation. Originally approved by FDA as
  anti-depressant (WelbutrinR).
• Requires doctors prescription and medical
  monitoring
• Doubles quit rates vs placebo.

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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

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• Formulations
• gum (2, 4 mg NicoretteR)--available OTC
• patch (up to 21 mg e.g. NicodermR)
• --available OTC
• nasal spray (NicotrolR)
• inhaler
• lozenge

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Women did worse than men on gum and tended to do
worse on patch and spray, but women better than
men on inhaler.
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INSERT FIG SHOWING KINETICS OF CIGS AND NRT, to
illustrate why NRT might not work that well
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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)

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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

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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. 198926175-79. Marwick.
JAMA. 19962761291