Real World Quitting: Its Not What You Think John R Hughes John.hughes@uvm.edu

Disclosure I have received consulting and speaking fees and research grants from many for –profit companies who develop smoking cessation medications, products and services. I also have received consulting fees from non-profit organizations engaged in tobacco control advocacy. I serve (without pay) on the Swedish Match (makers of snus) Advisory Board.

Two Ways to Increase Quitting Increase quit attempts Increase success of quit attempts

Purpose of Our Natural History Studies To describe attempts to change (i.e. quit attempts, reduction, lapses, and relapses) in a real-world setting To determine if environmental cues determine onset of a quit attempt

Methods Daily smokers who intended to quit at some point in the next 3 months Participants recruited from across US We did not provide any treatment Study was conducted by phone, mail and internet

Interactive Voice Response Uses phone keypad to enter data Increases report of stigmatized behaviors With payments and prompts, we obtain high compliance (< 5% missing over 3 months)

Sample Characteristics For Tobacco Study Mean age = 45 Mean cigs/day = 19 Mean FTCD = 5.3 (moderately dependent) More like self-quitters than treatment seekers

Logical Sequence of Quitting Cues to quit occur Decide to quit Consider treatment Set a quit date Attempt to quit Return to smoking Try again several months or years later

Current Conceptualization of Smoking Cessation    I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 DAY I Smoke as usual Abstinence Intent-to-quit

Examples of Real World Quitting   I Smoke as usual Intention NOT to smoke Abstinence Reduction

Major Results 71% of smokers made multiple attempts to stop and often rapidly changed among smoking as usual, reduction and quit attempts. Reduction as common as quitting

Major Results 72% of quit attempts not preceded by intent to quit night before Intention to quit the next day often (84% of the time) did not lead to a quit attempt Most (79%)of quit attempts did not last a day Quit attempt failure predicted more, not less, future quitting Little evidence of quit fatigue over 3 months

Percent of Quit Attempts That Are Unplanned

Cues to Quit Smoking Embarrassed 49 Cost 46 Asked to quit 39 Media cue Percent of participants in which cue occurred weekly Embarrassed 49 Cost 46 Asked to quit 39 Media cue 41 Smoking-related symptom 19 Friend quit smoking 10 Smoker you know has tobacco related symptom 4 Your smoking effects others 1

Cues to Quit and Their Effect More cues = greater probability of a quit attempt Embarrassment was the most common cue, but is rarely cited as motivator Cost was the most influential cue in prospective analysis, but is rarely cited as a motivator Health concerns was most cited reason for quitting but was a rare and non-influential cue

More Cues = More Quitting Among Smokers

A Different Conceptualization of Behavior Change

Lay Explanations of Behavior Change Cathartic event Sudden insight Large contingency Solid decision to change: “Just Do It”

In this scenario, a MD advises cessation and the smoker states not interested, then spouse asks smoker to stop, then kids, then friends, then uncle dies of cancer and then 1 yr after MD advises cessation, smoker stops seemingly due to seeing uncle die of lung cancer. MD concludes his/her advice had no effect

In this scenario, MD advice and uncle getting lung cancer have been switched in time. So now when MD sees smoker, he/she has already had many prompts to stop and when MD gives advice, smoker decides to stop. MD concludes he/she is great motivator. But take-home message is that a decision to stop smoking is like all decisions; I.e, it is highly influenced by the number of people who comment on it. Thus, a MD needs to put in his brief advice mostly because he/she knows it is moving the smoker closer to eventually quitting and that, as stated earlier, it may make the smoker stop before that cancer begins or that heart attack occurs.

Increasing Quit Attempts Intensity of advice or how convincing advice is, is probably not that important 99% of time, the clinician will never see the effect of the advice; thus, advising is an act of faith Repeating the advice at intervals (e.g. every 3 months) important

Effect of Not Presenting Cue When clinicians do not mention smoking, smokers conclude Clinician thinks smoking is not that problematic (41%) Clinician does not think I can change (46%)

Implications of Our Model Change is messy- lots of fits and starts Best not to focus on any individual attempt, better to focus on helping person across several attempts Persistence may be a key to changing Important for all clinicians to advise smokers to quit even though they will see no evidence it was effective “Revolving door” effect is a desired outcome