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

2. 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)

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

4. 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

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

6. Withdrawal Symptoms MOOD COGNITIVE Depression Irritability Anxiety
Difficulty concentrating

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

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

9. 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

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

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

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

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

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

15. 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

16. 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

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

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

19. 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.”

20. 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”?

21. 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: )