1. 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

2. 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

3. Motivating Patients to Quit Some 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

6. What about cutting down?

7. What about switching to lights?

8. 1.Do you smoke? 2.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? “ASK” dependence antecedents Impact treat.

9. 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 workplace Environmental risks Smoker reports perceived inability to quit Low self-efficacy Smoker reports not being ready to quit Low readiness to change Smoker reports low motivation to quit Low motivation Depression, schizophrenia, alcoholism, other chemical dependency Psychiatric Comorbidity Smoker reports severe withdrawal during previous quit attempts High nicotine dependence Examples Variable

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

11. “ASSIST” 1.Medication (NRT, Zyban) : Give clear instructions & expectations 2.Behavioral counseling (essential) a.Heighten motivation b.Set quit date c.Ask about and deal with anticipated difficulties d.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)

12. 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

13. Zyban R (bupropion) SR First non-nicotine medication approved by FDA for smoking cessation. Originally approved by FDA as anti-depressant (Welbutrin R ). Requires doctor’s prescription and medical monitoring Doubles quit rates vs placebo.

14. 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

15. Formulations: gum (2, 4 mg; Nicorette R )--available OTC patch (up to 21 mg; e.g. Nicoderm R ) --available OTC nasal spray (Nicotrol R ) “inhaler” lozenge

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

18. INSERT FIG SHOWING KINETICS OF CIGS AND NRT, to illustrate why NRT might not work that well

21. 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)

23. “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

24. 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