Innovative
Approaches to
Smoking Cessation
Treatment
Scott M. Strayer, MD, MPH
Assistant Professor
University of Virginia, Dept. of Family
Medicine
Center for Information Mastery
PinnacleHealth Hospitals Grand Rounds 2005
Copyright© 2005 Scott Strayer
Objectives
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Describe the latest evidence for treatments during
smoking cessation, including the use of tricyclic
anti-depressants in adults and patches in
adolescents.
Be able to describe the key components of
“Motivational Interviewing” and the “Stages of
Change” and how they are used in smoking
cessation counseling.
Identify web-based and computer resources that
assist physicians with smoking cessation
counseling.
Identify web-based and computer resources that
assist patients with smoking cessation.
How well do we address
smoking cessation?
• Not very well!!
– Only 35% of Physicians assist with
smoking cessation attempts (Thorndike
AN, Rigotti NA, Stafford RS, Singer DE.
National patterns in the treatment of
smokers by physicians. JAMA 1998;
279:604-608).
What We Know…
• Tobacco dependence is a chronic
condition that often requires
repeated intervention.
• Because effective tobacco
dependence treatments are available,
every patient who uses tobacco
should be offered at least one of
these treatments.
• It is essential that clinicians and
health care delivery systems
(including administrators, insurers,
and purchasers) institutionalize the
consistent identification,
documentation, and treatment of
every tobacco user seen in a health
care setting.
• Brief tobacco dependence treatment
is effective, and every patient who
uses tobacco should be offered at
least brief treatment.
• There is a strong dose-response
relation between the intensity of
tobacco dependence counseling and
its effectiveness.
• Three types of counseling and behavioral
therapies were found to be especially
effective and should be used with all
patients attempting tobacco cessation:
• Provision of practical counseling
(problemsolving/skills training).
• Provision of social support as part of
treatment (intra-treatment social support).
• Help in securing social support outside of
treatment (extra-treatment social support).
• Numerous effective pharmacotherapies for smoking
cessation now exist. Except in the presence of
contraindications, these should be used with all
patients attempting to quit smoking.
• Five first-line pharmacotherapies were identified that
reliably increase long-term smoking abstinence rates:
• Bupropion SR.
• Nicotine gum.
• Nicotine inhaler.
• Nicotine nasal spray. Nicotine patch.
• Two second-line pharmacotherapies were identified as
efficacious and may be considered by clinicians if firstline pharmacotherapies are not effective:
• Clonidine.
• Nortriptyline.
• Over-the-counter nicotine patches are effective relative
to placebo, and their use should be encouraged.
• Tobacco dependence treatments are
both clinically effective and costeffective relative to other medical
and disease prevention
interventions.
Is It Possible?
• To deliver all the preventive services
recommended by the USPTF to an
average panel of patients, family
physicians would need to spend 7.5
hours of every working day on
prevention
Yarnell KS, Pollac KI, Ostbye T, Krause KM, Michener JL. Primary care: is
there enough time for prevention? AM J Public Health 2003;93:635-41.
Leveraging 1 Minute for
Prevention
1 minute is the realistic average amount
of time that primary care providers can
devote to prevention during a typical
office visit
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The
power of leveraging to fulfill the promise of health behavior counseling.
Am J Prev Med, 2002; 22:320-323.
Opportunities for Intervention
• Most people visit a primary care doctor about
three times per year.
• Even 2-3 minute interventions are effective,
especially when followed up with telephone,
e-mail, nurse calls, referrals, 1-800 numbers,
etc.
• Many primary care providers provide 2-3
minute health promotion/behavior
interventions at every outpatient visit.
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of
leveraging to fulfill the promise of health behavior counseling. Am J Prev Med,
2002; 22:320-323.
The other elements of brief
health promotion
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Goal setting
Specific Behavior Change Techniques
Self-help Materials
Regular Follow-up
New strategies, tools
and technical
assistance are needed
to tailor these more
complex interventions
to the realities of
current primary care
practice.
RWJ Foundation, Prescription
for Health Initiative
PinnacleHealth Hospitals Grand Rounds 2005
Copyright© 2005 Scott Strayer
In the 1 minute devoted to
preventive/behavioral issues,
the doctor can either “plant
the seed” for Interactive
Behavioral Change
Technology (IBCT) to
cultivate after the visit, or
“reap the fruit” of IBCT
interventions that have taken
place prior to the visit.
Glasgow R, Bull S, Piette J, Steiner J. Interactive behavior change technology:
A partial solution to the competing demands of primary care. Am J Prev Med
2004; 27:80-87.
Glasgow R, Bull S, Piette J, Steiner J. Interactive behavior change technology: A partial solution to the
competing demands of primary care. Am J Prev Med 2004; 27:80-87.
Behavioral Change Theories
• Stages of Change----assess patient’s
readiness to change and then deliver
stage-appropriate interventions
• Motivational Interviewing---a nonconfrontational technique for helping
patients change their health behavior
Stages of Change
• Pre-contemplation-pt is not ready to
initiate change.
• Contemplation-pt is considering making
change in next 6 months.
• Preparation-pt is ready to make change
in 30 days.
• Action-pt is making change.
• Maintenance-pt has made change.
Motivational InterviewingDARES
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Develop Discrepancy
Avoid Argumentation
“Roll with Resistance”
Express Empathy
Support Self-Efficacy
Integrating the Behavioral
Theories
Not
Stage-dependent
• Ask
• Advise
Smoking and BMI as
Vital signs
• Assess
Stages of Change
Motivational Interviewing
• Assist
• Arrange
Use Motivational
Interviewing
Stage-based interventions
Motivational Interviewing
Local and national
resources
Programs for Physicians
• MLIT
• HCSIT (www.smokefree.gov)
• Calculators (www.statcoder.com and
http://hin.nhlbi.nih.gov/atpiii/atp3palm.htm)
• C-Tools 2.0
(http://www.cancer.org/docroot/COM/content/
div_TX/COM_5_1x_The_CTools_20.asp?SiteArea=)
• Websites
Development of the MLIT
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Operationalize the Stages of Change
Identify stage based interventions
Scripted motivational interviewing
Risk calculators
Pharmacotherapy info
Local and national resources
Modular design
C-Tools
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Guidelines for smoking cessation
Pharmacotherapy Information
Websites
Quitline numbers
InfoRetriever 2005
Windows 95/98/NT/ME/2000/XP, PocketPC, Palm and Web
2200+ short research
synopses (400 added
per year)
5 Minute Clinical
Consult
Cochrane Database
of Systematic Reviews:
over 1750+ abstracts
200+ clinical
prediction
rules
Basic drug
info by class
and cost for
1200 drugs
Bayesian
diagnostic
test / H&P
calculator
(2000+)
Key evidence-based
treatment guidelines
www.InfoPOEMs.com
InfoRetriever to help with
treatment decisions
• A 46 y/o male, smoker
– PMH significant for hypertension treated
with HCTZ. Most recent BP = 138/86.
– FH: Both parents have HTN over age 70,
no h/o CAD.
– Lipids: Chol = 197; HDL = 41; LDL = 141.
• Questions:
– What is his risk of an AMI or sudden
cardiac death in the next 10 years?
– How much will lowering the SBP below
130 reduce the risk?
– How much will stopping smoking affect
his risk?
Should his SBP be lowered
to <130?
What if he quit smoking
instead?
What if your patient asks
about?
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Smoking Cessation Quitlines
Accupuncture
Hypnotherapy
Tricyclics
Is the patch effective in adolescents?
Websites for Physicians
• Treating Tobacco Use and Dependence
(http://www.surgeongeneral.gov/tobacco
/default.htm)
• NCI website (www.smokefree.gov)
• American Cancer Society
(www.cancer.org)
• American Lung Association
(www.lungusa.org)
Programs for
Patients
PinnacleHealth Hospitals Grand Rounds 2005
Copyright© 2005 Scott Strayer
RWJ MyHealthyLiving Website
• www.pubinfo.vcu.edu/myhealthyliving/
• Have patients enter “Physician not
entered here.”
American Cancer Society
• www.cancer.org/quittobacco
• Online resources for patients and
providers
• Localized resources
• Tobacco Cessation Leadership Institute
(UCSF)
American Lung Association
• Patient Resources
• Freedom From Smoking Online
Finding PDA Programs
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www.pdamd.com
www.aafp.org
www.handango.com
www.palmgear.com
Smoking Cessation
My Last Cigarette
Features:
Nicotine level readout
Expected cravings readout
Deaths since you quit readout
Daily motivational message
Carbon Monoxide level of your blood
Increase in life expectancy readout
Time you have been a non smoker readout
Number of cigarettes NOT smoked readout
Your risk of a heart attack compared to your risk before
Your risk of lung cancer compared to your risk before
Expected circulatory improvement
Expected lung function improvement
Readouts updated every second and are based upon your own personal past smoking
habits.
All calculations are based upon the latest medical knowledge and statistics.
Quitability
• Identify key
personal motivators
• Identify triggers and
how to cope with
them
• Help with changing
environment
• Coping with lapses
Does it Work?
Physician performance improved (43/65)
Drug dosing systems (9/15)
Diagnostic aids (1/5)
Preventive care systems (14/19)
Clinical decision support systems(19/26)
Patient outcomes improved (6/14)
JAMA, October 21, 1998. Vol 280, No. 15, pp 1339 -1346.
Tailored Smoking Cessation
Messages for Patients Work
• Orleans CT, Boyd NR, Noll E, Crosette L. Intervening
through a prescription benefit plan for nicotine patch
users. Paper presented at the Society of Behavioral Medicine
Annual Meeting.Washington DC, March 1996.
• Prochaska JO, DiClemente CC, Velicer WF, Rossi JS.
Standardized, individualized, interactive and personalized
self-help programs for smoking cessation. Health Psychol
1993;12:399–405.
• Shiffman S, Gitchell J, Strecher V. Real-world efficacy of
computer-tailored smoking cessation material as a supplement
to nicotine replacement. 10th Conference on
Tobacco or Health, Beijing, August 1997.
PDA’s and Asthma
A guideline implementation system using handheld computers for office management of
asthma: effects on adherence and patient outcomes.
Shiffman RN, Freudigman M, Brandt CA, Liaw Y, Navedo DD.
Department of Pediatrics, Yale School of Medicine, New Haven, CT 06520-8009, USA.
richard.shiffman@yale.edu
OBJECTIVE: To evaluate effects on the process and outcomes of care brought about by use of a
handheld, computer-based system that implements the American Academy of Pediatrics guideline on
office management of asthma exacerbations. DESIGN: A before-after trial with randomly selected,
office-based Connecticut pediatricians. In both the control and intervention phases, physicians
collected data from 10 patient encounters for acute asthma exacerbations. During the intervention
phase, the computer provided for structured encounter documentation and offered recommendations
based on the guideline of the American Academy of Pediatrics. Patients were contacted by telephone
7 to 14 days after the visit to assess outcomes. RESULTS: Nine study-physicians enrolled 91
patients in the control phase and 74 in the intervention phase. Follow-up information was available
for 93% of encounters. Use of the intervention was associated with increased mean frequency/visit
of: 1) measurements of peak expiratory flow rate (2.18 vs 1.57) and oxygen saturation (1.12 vs.42),
and 2) administration of nebulized beta2-agonists (1.25 vs.71). Visits in the intervention phase lasted
longer and fees were higher ($145.61 vs $103.11). There were no significant differences in
immediate disposition or subsequent emergency department visits, hospitalizations, missed school,
or caretaker's missed work during the 7 days post visit. CONCLUSION: Use of handheld computers
that provide guideline-based decision support was associated with increased physician adherence to
guideline recommendations; however, visits were prolonged, fees were higher, and no improvement
could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline
implementers (and users) should be cautious about putting unvalidated recommendations into
practice.
More Evidence is on the way
• Robert Wood Johnson Prescription for
Health initiative
• AHRQ PDA Tools Evaluation
• National Cancer Institute Evaluations
• Try it in your practice and collect data
on outcomes