1. Real World Quitting: Its Not What You Think
John R Hughes

2. 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.

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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. Examples of Real World QuittingI
Smoke as usual
Intention NOT to smoke
Abstinence
Reduction

12. 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

13. 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

14. Percent of Quit Attempts That Are Unplanned

15. 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

16. 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

17. More Cues = More Quitting Among Smokers

18. A Different Conceptualization of Behavior Change

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

20. 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

21. 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.

22. 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

24. 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%)

25. 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