introduction to smoking cessation mssm iii edward anselm, m.d. assistant professor of medicine icahn...
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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
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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
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New York City Trends
*Chart from NYC DOHMH available at www.nyc.gov
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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
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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
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Targeted Marketing
• Women
• Young People
• Racial and Ethnic Minorities
• Lesbian/Gay/Bisexual/Transgender
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Role of the Physician
Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up
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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
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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
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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?
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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:
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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?”
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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?
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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
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• A CONTRACT TO QUIT SMOKING
•
• AGREE TO QUIT SMOKING ON _________________
•
• I WANT TO QUIT SMOKING BECAUSE___________________
•
• MY REWARDS WILL BE __________________________
•
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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
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Arrange follow-up
Telephone Office visitFind out what went wrongAsk patient to recommit to plan
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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
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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
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Role of the Physician
Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up
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The Behavior of Smoking I
Early Experimentation
Brand Identification
Regular SmokersChippers
Light Smokers
Heavy Smokers
Interest in quitting
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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)
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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
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Nicotine Withdrawal
Anxiety
irritability
anger
restlessness
difficulty concentrating
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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
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Methods of Smoking Cessation
Self Help
Physician Advice
Counseling
Social Support
Telephonic Support and Advice
Smoking Cessation Classes
Medication
Hypnosis/Acupuncture
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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
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Why do people relapse?
Nicotine withdrawalAlcoholStressSocial situation
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What to do if your patient relapses
Find out why
More intensive treatment
Referral for intensive program
Psychiatric evaluation
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Use of Medication
Nicotine PatchNicotine Gum, Nasal SprayNicotine Lozenge, InhalerBuproprion, and other AntidepressantsCombination TherapyVarenicline (Chantix)RimonibantNicotine Vaccine
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Role of the Physician
Ask about smokingAdvise tobacco users to quitAssess readiness to quitAssist with a plan for quittingArrange follow-up
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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
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Tobacco Use and Mental Health
• Nicotine and self medication
• Episodic mood management
• Depression
• Substance abuse
• Anxiety Disorders
• OCD, ADD
• Schizophrenia
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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
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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
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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
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