Clinical Trials and Patient Education for Smoking Cessation Maureen George PhD RN AE- C FAAN University of Pennsylvania School of Nursing

Number of new smokers is unchanged –Few start after age of 25 –No change in the lowest income groups 36% of year olds are smokers More men are quitting or not starting Increasing cost decreases smoking rates

Why do people smoke? When initiating smoking –Risk denial; Unrealistic optimism –Social aspects When continuing to smoke –Social activity, stress reduction, “approved” break –Perceived lack of control over behavior –Enjoy the effects –Develop dependence

Characteristics of Dependence Clinical Assessment Morning smoking behaviors Smoke > 1 ppd Sneak cigarettes Smoke when ill Time intensive Conditioned response Physical Assessment Tolerance Useful effects Withdrawal symptoms – Drug seeking Know health hazards

Key components in cessation educational interventions Motivation; not fear arousal communication Support Reducing exposure to second hand smoke Linking health messages back to the product

Educational interventions must be targeted Gender Those most resistant to quitting High-risk smokers –Menthol cigarettes Benefits of cessation at any time

Benefit to quitting smoking at any age

What can we do to help smokers quit? How do you define success? 2/3rds of smokers use ineffective methods –NRT 8-30% success –Psychological approaches 10-20% success Multiple approaches best

The 5 A’s Ask at every contact Advise to quit Assess willingness Assist in making quit plan Arrange f/u

Give smoking cessation message at each visit “Quitting is difficult for everyone. As your (nurse/doctor) I have an obligation to tell you that smoking is bad for your health. I can tell you about the benefits to quitting and can help you whenever you’re ready to quit.”

Principles of Motivational Interviewing MI is a client-centered method for enhancing motivation to change by exploring and resolving ambivalence –Advise –Remove barriers –Provide choice –Express empathy, share your understanding of their perspective; curiosity but low investment –Provide feedback that creates discrepancy, –Clarify goals –Actively help Roll with resistance, accept their reluctance to change as natural rather than pathological. Support self-efficacy, embrace their autonomy (even when they choose to not change) and help them move toward change successfully and with confidence. Avoid argumentation (and direct confrontation).

Potential impact 70% of smokers see a physician annually – ~ 33 million adult smokers If 50% of physicians delivered a brief quitting message and were successful 1 in 10 times, there would be1.75 million new ex-smokers every year. – more than double the national annual quit rate.

Barriers to quit advice Physicians feel unprepared or ineffective to help their patients quit Physicians do not receive smoking cessation intervention training in medical school Lack of time and reimbursement Nurse advise may best fit within a team provider approach or be accompanied by specialized training Cantor et al., 1993; Cummings et al., 1989; Spangler et al., 2002; Ferry et al., 1999; Fiore et al., 1994; Fiore et al., 2000 Gorin & Heck, 2004;

Factors associated with successful quitting Having made previous attempt(s) Has a plan for avoiding temptation Uses cigarette reduction rather than cold turkey Older age Higher SES Has a significant other

The 5 R’s: Treating patients who are not ready to quit

Clinical open trials Most are trials of products –Several seek to see what quit rates are when treatment is free –CAM Exercise Relaxation Yoga Hypnotherapy MBSR Auricular acupressur e Testing in all patient groups Pregnancy Prisoners Expectant Latino fathers Overweight Veterans American Indians Substance users Mental health disorders Adolescents Medical conditions

Clinical Testing at all POC EDs Pre-admission Inpatient Outpatient Testing all approaches Behavioral Drug Technology- assisted – Web-based, – Mobile phones: SMS support – IVR Individual vs. group Quit and win contests Testing messages specific for literacy levels