1. Introduction to Smoking Cessation MSSM III Edward Anselm, M.D. Assistant Professor of Medicine Icahn School of Medicine at Mount Sinai Medical Director, Health Republic Insurance of New Jersey EdwardAnselmMD.com eanselm@msn.com

3. 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

4. New York City Trends * Chart from NYC DOHMH available at www.nyc.gov

5. Adult Smoking in NYC Down Almost 27% Since 2002 % of adults City and State tax increases Smoke-free workplaces Free patch programs 3-yr average Hard-hitting media begins 16.4% decline since 2005 State tax increase Federal tax increase

6. Over 75% of smokers recall having been advised to quit smoking in 2012 Discussing Cessation Strategies –Commercial Medicaid HMO PPOHMO 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

11. Targeted Marketing Women Young People Racial and Ethnic Minorities Lesbian/Gay/Bisexual/Transgender

12. Role of the Physician Ask about smoking Advise tobacco users to quit Assess readiness to quit Assist with a plan for quitting Arrange follow-up

13. The Role of the Physican Five “A”s Ask about smoking Advise tobacco users to quit Assess readiness to quit Assist with a plan for quitting Arrange follow-up Every patient quitting cigarettes should be offered a medication Two “A”s + R Ask about smoking Advise tobacco users to quit Refer to cessation services Five “R”s Relevance Risks Rewards Roadblocks Repetition

14. Effect of General Practitioners’ Advice Against Smoking Russell, MAH et al,, BMJ 1979 2, 231-5

15. 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?

16. Vital Signs Stamp VITAL SIGNS Pulse: Temperature: Respiratory Rate: (circle one) CurrentFormer Never Tobacco Use: Blood Pressure: Weight:

17. 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?”

18. 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?

19. 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

20. A CONTRACT TO QUIT SMOKING AGREE TO QUIT SMOKING ON _________________ I WANT TO QUIT SMOKING BECAUSE___________________ MY REWARDS WILL BE __________________________

21. COST OF SMOKING in NYC Cost of a pack$10.25 PacksNumber ofCost per dayper monthper year percigarettes dayper day 0.510 $ 5.13 $153.75 $ 1,870.63 120 $10.25 $307.50 $ 3,741.25 1.530 $15.38 $461.25 $ 5,611.88 240 $20.50 $615.00 $ 7,482.50 360 $30.75 $922.50 $11,223.75

22. Arrange follow-up Telephone Office visit Find out what went wrong Ask patient to recommit to plan

23. 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

24. 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

25. Role of the Physician Ask about smoking Advise tobacco users to quit Assess readiness to quit Assist with a plan for quitting Arrange follow-up

26. The Behavior of Smoking I Early Experimentation Brand Identification Regular Smokers Chippers Light Smokers Heavy Smokers Interest in quitting

27. 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)

29. 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

30. Nicotine Withdrawal Anxiety irritability anger restlessness difficulty concentrating

31. The Natural History of Smoking Cessation 50 Million former smokers 5-8 efforts to quit smoking Each effort resulted in longer periods of abstinence from smoking Process over several years

32. Methods of Smoking Cessation Self Help Physician Advice Counseling Social Support Telephonic Support and Advice Smoking Cessation Classes Medication Hypnosis/Acupuncture

33. 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

34. Why do people relapse? Nicotine withdrawal Alcohol Stress Social situation

35. What to do if your patient relapses Find out why More intensive treatment Referral for intensive program Psychiatric evaluation

37. Use of Medication Nicotine Patch Nicotine Gum, Nasal Spray Nicotine Lozenge, Inhaler Buproprion, and other Antidepressants Combination Therapy Varenicline (Chantix) Rimonibant Nicotine Vaccine

39. Role of the Physician Ask about smoking Advise tobacco users to quit Assess readiness to quit Assist with a plan for quitting Arrange follow-up

40. JAMA 2000 Nov 22-29; 284 (20): 2606-10 Smoking and Mental Illness

41. Tobacco Use and Mental Health Nicotine and self medication Episodic mood management Depression Substance abuse Anxiety Disorders OCD, ADD Schizophrenia

42. 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

43. 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

44. 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