Anita R. Webb, PhD JPS Family Medicine Residency Smoking Cessation Anita R. Webb, PhD JPS Family Medicine Residency

By the Numbers Leading preventable cause of disease and death in U.S. 440,000 deaths every year $157 billion health-related costs/year (Surgeon General’s Report 2004)

Quitting What % of smokers want to quit? How many attempts to succeed? Answers 70% Nine

Example: Tarrant County, Texas What percentage of population smokes? Percent who have attempted to quit in the last 12 months? Answers 22% smoke (more males) 55% attempted to quit in the last 12 months

Obstacles Withdrawal symptoms Smoker in the home Smokers at work Stress Psychiatric disorder

Withdrawal Symptoms MOOD COGNITIVE Depression Irritability Anxiety Difficulty concentrating

Withdrawal Symptoms (continued) Insomnia Decreased heart rate Weight gain How much? 6 pounds on average

Withdrawal: Duration? How long for symptoms to subside? Within one month How many quitters still crave cigarettes After 6 months? 50%

Diagnosing Two Questions Answers: 1. How soon after you wake up do you smoke your first cigarette? 2. How many cigarettes do you smoke per day? Answers: 30 minutes = High dependence 20 cigarettes per day = High dependence

Effective Treatments? “Cutting Down”? Pharmacotherapy? Physician Counseling? Psychotherapy? Behavior Modification

“Cutting Down” Yes or No? NO: “Compensatory smoking” Inhale stronger, longer, deeper Increases exposure to Smoke Carbon monoxide Carcinogens

Pharmacotherapy FDA approved cessation products Nicotine Replacement Therapy (NRT) Gum (OTC) Patch (OTC) Lozenge (OTC) Inhaler Nasal spray Buproprion

Helpful? 25% who use pharmacotherapy NRT’s increased: Eventually quit Usually after several attempts NRT’s increased: Odds of quitting by a factor of 1.5 - 2 Abstinence for 6 months (Buproprion about the same) (Cocharane Database Syst Rev. 2004;3:CD000146)

Best Pharmacotherapy? No difference between pharmacotherapies In terms of: Withdrawal Craving Patient satisfaction

Over-the-Counter Products Patients often use them incorrectly Not long enough (requires 6-12 weeks) Improper methods Example: Nicotine Gum Chew slowly Hold in cheek to prolong absorption Avoid acidic beverages (coffee, soda, juice) for 30 minutes before and after gum

E-Cigs? Electronic Cigarettes “Our data add to the current evidence that e-cigarettes “May not increase rates of smoking cessation.” Katz, MH. JAMA Internal Med 3/24/2014

Cessation Counseling Counseling + Pharmacotherapy Doubles the success rate of smoking cessation

Treatment “Five A’s” ASK: Every patient, every visit ADVISE: To quit ASSESS: Willingness to quit ASSIST: Counseling + pharmacotherapy ARRANGE: Follow-up first week

Counseling Rationale Let patients make their own argument for quitting. Through gentle questioning: “Good things” questions “Bad things” questions “When people listen to themselves talk “They shape their thinking.”

RESISTANCE What might happen when the physician makes the argument for quitting? Patient “resistance” One possible theory for resistance: To maintain personal autonomy vs. following physician’s “commands”?

Conclusions Asking patients about smoking may increase smoking cessation. Products help some patients to quit. Counseling + products recommended Be patient: “Ride with the resistance.” (Lamberg, L. Patients need more help to quit smoking: Counseling and pharmacotherapy double success rate. JAMA 2004;292:1286-88)