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Practical steps to smoking cessation
ESS A YS I N P R EV EN T IO N
Practical steps to smoking cessation Thomas E. Kottke, MD, MSPH, Professor of Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905
BACKGROUND For most smokers, their use of tobacco is the greatest single threat to health – half of the smokers will have their lives shortened by tobacco.1 All clinicians have a responsibility to address this threat. Systematically analyzing the clinical trials of smoking cessation interventions, the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline Panel and Staff identified three critical elements that give smoking cessation interventions their efficacy: skills building, social support for cessation and nicotine replacement.2 The panel and staff also emphasized that a health services delivery system that expects and supports smoking cessation intervention must be in place if these interventions are to be delivered with appropriate requency. In the period since the AHCPR panel issued its report, evidence has accumulated that leadership in the clinic and in the community is also needed to assure that the smoker is provided with the assistance and environment that she or he wants and needs to abstain from tobacco use. This Essay in Prevention will briefly address each of these topics with the goal of helping clinicians reduce the burden that tobacco places on their patients. SKILLS BUILDING Over the past two decades, Prochaska and others have developed what they refer to as the Transtheoretical Model of Change (TMC).3 Physicians will find that this model is consistent with their clinical experience. Research on the Transtheoretical Model of Change demonstrates the benefits of identifying the smoker’s readiness to change before attempting to intervene. Each stage of change (precontempation – not thinking about quitting smoking; contemplation – thinking about quitting but not yet committed; preparation – getting ready to quit; action – trying to quit; and maintenance – trying to remain abstinent) is best addressed with a particular type of information and intervention. For example, the smoker who is not considering quitting (and is thus in the precontemplation stage) is most likely to be helped by an intervention that increases information about themselves and their problem (‘‘You would breathe better if you quit smoking. Is there anything that I can do to help?’’). A smoker in the contemplation stage could be expected to benefit from self-reevaluation (‘‘You are considering quitting. I’d like you to make a list of the pros and cons of quitting. I think you’ll be surprised by the number of benefits to quitting that you can identify’’). A smoker in the preparation phase is likely to benefit from an intervention that generates self-liberation (‘‘You can increase your chances of quitting smoking by promising yourself that you will not smoke’’). Smokers in the action and maintenance stages are likely to benefit from counterconditioning and stimulus control (‘‘Getting up and taking a brief walk can help you deal with urges to smoke’’, or ‘‘Becoming and remaining free of tobacco will be easier if you stay away from places where people smoke’’). Research conducted with the Transtheoretical Model of Change has revealed 10 processes of change that appear to be used by smokers of all ages who are in the process of quitting.4 Four of the processes (consciousness raising, dramatic relief, environmental 4
Evidence-based Cardiovascular Medicine (1999) 3, 4d5
reevaluation, and self-reevaluation) are experiential – that is, they are related to how the smoker views himself or herself in relationship to their environment.4 Six are behavioral (establishing helping relationships, stimulus control, counterconditioning, reinforcement management, social liberation and self-liberation) – they are related to how the smoker behaves. Experiential processes tend to be used when moving from precontemplation to contemplation and preparation. Behavioral processes tend to be used when moving from preparation to action and maintenance. The physician can easily become facile in identifying the smoker’s stage of change and in helping the smoker apply the change process that is correct for that stage. This skill increases both the success rate of smoking cessation interventions and the sense of reward gained from helping smokers quit. SOCIAL SUPPORT FOR QUITTING In addition to the behavioral skills discussed above and nicotine replacement (or prescribing bupropion hydrochloride) discussed below, social support for cessation helps the smoker quit.2 Social support increases the smoker’s desire to quit, helps the smoker acquire the skills to become and remain abstinent, and reinforces actions that have been taken to quit smoking. The power of social support for quitting given by the clinician can be optimized by applying the concepts of the Transtheoretical Model of Change described above. While social support on an interpersonal level comes from family, friends and health-care providers, the power of a smoke-free environment to reinforce the message that not smoking is more acceptable than smoking should not be underestimated. NICOTINE REPLACEMENT The addition of nicotine replacement approximately doubles the efficacy of any particular smoking cessation intervention.2 Nicotine replacement is available as gum, transdermal patches, nasal spray, and inhalers. The patient’s preferences should be considered when selecting a nicotine delivery system. Karl Olaf Fagerstrom, for example, gives his patients a ‘‘grab bag’’ of the various delivery systems so that they can choose the one that they find most convenient and attractive (personal communication). The smoker should be advised to use enough replacement nicotine to keep cravings under control. Although many physicians are concerned that their patients may become addicted to nicotine replacement, it is this observer’s opinion that nicotine replacement is usually abandoned too quickly rather than used too long. It is helpful to keep in mind that smokers are addicted to nicotine long before they begin to use nicotine replacement devices, and some smokers may need nicotine replacement for years. Bupropion hydrochloride (Zyban姞), originally used clinically as an antidepressant, has also been found to be efficacious in the smoking cessation process.5 Although efficacy has been demonstrated in randomized clinical trials, the mechanism of action is not entirely clear. The Mayo Clinic Nicotine Dependence Center usually suggests starting bupropion hydrochloride at 150 mg daily for one week before the patient quits smoking and then increasing the dose to 150 mg twice daily for eight weeks. A history of seizures is a contraindication to the prescription of bupropion hydrochloride. Simultaneous use with nicotine replacement products increases efficacy. ^ 1999 Harcourt Brace & Co. Ltd
ACTIVISM AND LEADERSHIP It is inappropriate to believe that delivering smoking cessation interventions to one’s own patients in the clinical setting is sufficient to deal with the burden that tobacco places on individuals and entire populations. The root cause of widespread nicotine addiction – aggressive marketing of tobacco products to minors and young adults – cannot be ignored. Although the AHCPR report emphasized that each physician has an obligation to lead his or her organization to implement smoking cessation intervention systems,2 the panel’s conclusion that each physician must be active to prevent nicotine addiction was removed from the report in response to political pressure. While individual physicians have demonstrated exemplary personal leadership to counter the effects of nearly 50 years of tobacco industry lies and deception,7 activists in the State of California have led the way in reducing the per capita consumption of cigarettes in a defined population. Stan Glantz, on his list serve web site (http://www.smokescreen.org) suggests that the following lessons from California may be useful in other states. (Personal communication, Stan Glantz, February 5, 1999). E
E
E
An aggressive anti-tobacco advertising campaign combined with community-based programs that stress the need to create a smoke-free society can rapidly reduce tobacco use. A successful program is not simply directed at keeping kids from smoking; it strives to protect non-smokers from secondhand smoke and creates environments that facilitate smokers’ decisions to cut down or quit. The foundation of a successful campaign is the de-legitimization of tobacco use and de-normalization of the tobacco industry.
When the California program followed these principles, the rate of decline in tobacco consumption tripled and the rate of decline in smoking prevalence increased significantly.8 When the Governor Pete Wilson’s administration toned down, scaled back, and shifted the focus of the tobacco control program to children, progress slowed or stopped. Glantz emphasizes that young adults are the key population – for both the tobacco industry and the public health community. On the one hand, the tobacco industry is concentrating their marketing efforts on young adults to avoid criticism that they are targeting children but with clear recognition that young adults are the strongest role models for teens and young children. Young adults who smoke, by the very act of smoking, market tobacco use to children. On the other hand, young adults are open to pro-health messages because they are starting families (and are concerned about secondhand smoke), and they work in smoke-free environments. Young adults are a particularly important cessation target because quitting after only a few years of smoking avoids most of the health consequences of smoking.
^ 1999 Harcourt Brace & Co. Ltd
Glantz draws three critical lessons from tobacco control efforts in California: E E E
Non-smokers are as important an audience as smokers. The tobacco industry never gives up. The more effective the program, the more vigorously the tobacco industry and its allies will attack it.
As a corollary, the tobacco industry can always be expected to fight the implementation of tobacco control programs and, when that tactic fails, seek to subvert active programs by channeling them into unproductive activities such as concentrating solely on very young children. In 8 years, the California Tobacco Control Program has prevented 2 billion packs of cigarettes (worth $3 billion to the tobacco industry) from being smoked. This has resulted in teen smoking rates that are well below the increases that occurred nationally. It can be estimated that the program has prevented more than 14 000 heart attacks and strokes, deferred death for over 2500 individuals, and prevented low birth weight for over 10 800 infants. The $500 million in medical costs that were avoided from these causes of death alone amounted to more than the anti-smoking media and community programs cost. More detailed information about the California tobacco program will be available in a forthcoming book by Glantz and Balbach to be published by the University of California Press, California Tobacco Wars. SUMMARY Smoking cessation intervention is a critical skill for any physician, and the particular components that generate efficacy have been identified: skills building, social support for cessation, and nicotine replacement. The clinician who understands how to use the Transtheoretical Model of Change will be more successful in applying interventions and will find intervention more satisfying. However, no smoking cessation intervention can be considered complete unless there is a component of leadership and activism to set the agenda for tobacco control both in the clinic and the community. Literature cited 1. Doll R, Peto R, Wheatley K et al. BMJ 1994; 309: 901d911 2. Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 1996; 275(16): 1270d1280 3. Prochaska JO, DiClemente CC, Norcross JC. Am Psychol 1992; 47: 1102d1114 4. Pallonen UE. Prev Med 1998; 27: A29dA38 5. Hurt RD, Sachs DPL, Glover ED et al. N Engl J Med 1997; 337: 1195d1202 6. Jorenby DE, Leischow SJ, Nides MA et al. N Engl J Med 1999; 340:685d691 7. Hurt RD, Robertson CR. JAMA 1998; 280: 1173d1181 8. Pierce JP. Gilpin EA. Emery SL et al. JAMA. 1998; 280: 893d899
Evidence-based Cardiovascular Medicine (1999) 3, 4d5
5
Practical steps to smoking cessation Thomas E. Kottke, MD, MSPH, Professor of Medicine, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905
BACKGROUND For most smokers, their use of tobacco is the greatest single threat to health – half of the smokers will have their lives shortened by tobacco.1 All clinicians have a responsibility to address this threat. Systematically analyzing the clinical trials of smoking cessation interventions, the Agency for Health Care Policy and Research (AHCPR) Smoking Cessation Clinical Practice Guideline Panel and Staff identified three critical elements that give smoking cessation interventions their efficacy: skills building, social support for cessation and nicotine replacement.2 The panel and staff also emphasized that a health services delivery system that expects and supports smoking cessation intervention must be in place if these interventions are to be delivered with appropriate requency. In the period since the AHCPR panel issued its report, evidence has accumulated that leadership in the clinic and in the community is also needed to assure that the smoker is provided with the assistance and environment that she or he wants and needs to abstain from tobacco use. This Essay in Prevention will briefly address each of these topics with the goal of helping clinicians reduce the burden that tobacco places on their patients. SKILLS BUILDING Over the past two decades, Prochaska and others have developed what they refer to as the Transtheoretical Model of Change (TMC).3 Physicians will find that this model is consistent with their clinical experience. Research on the Transtheoretical Model of Change demonstrates the benefits of identifying the smoker’s readiness to change before attempting to intervene. Each stage of change (precontempation – not thinking about quitting smoking; contemplation – thinking about quitting but not yet committed; preparation – getting ready to quit; action – trying to quit; and maintenance – trying to remain abstinent) is best addressed with a particular type of information and intervention. For example, the smoker who is not considering quitting (and is thus in the precontemplation stage) is most likely to be helped by an intervention that increases information about themselves and their problem (‘‘You would breathe better if you quit smoking. Is there anything that I can do to help?’’). A smoker in the contemplation stage could be expected to benefit from self-reevaluation (‘‘You are considering quitting. I’d like you to make a list of the pros and cons of quitting. I think you’ll be surprised by the number of benefits to quitting that you can identify’’). A smoker in the preparation phase is likely to benefit from an intervention that generates self-liberation (‘‘You can increase your chances of quitting smoking by promising yourself that you will not smoke’’). Smokers in the action and maintenance stages are likely to benefit from counterconditioning and stimulus control (‘‘Getting up and taking a brief walk can help you deal with urges to smoke’’, or ‘‘Becoming and remaining free of tobacco will be easier if you stay away from places where people smoke’’). Research conducted with the Transtheoretical Model of Change has revealed 10 processes of change that appear to be used by smokers of all ages who are in the process of quitting.4 Four of the processes (consciousness raising, dramatic relief, environmental 4
Evidence-based Cardiovascular Medicine (1999) 3, 4d5
reevaluation, and self-reevaluation) are experiential – that is, they are related to how the smoker views himself or herself in relationship to their environment.4 Six are behavioral (establishing helping relationships, stimulus control, counterconditioning, reinforcement management, social liberation and self-liberation) – they are related to how the smoker behaves. Experiential processes tend to be used when moving from precontemplation to contemplation and preparation. Behavioral processes tend to be used when moving from preparation to action and maintenance. The physician can easily become facile in identifying the smoker’s stage of change and in helping the smoker apply the change process that is correct for that stage. This skill increases both the success rate of smoking cessation interventions and the sense of reward gained from helping smokers quit. SOCIAL SUPPORT FOR QUITTING In addition to the behavioral skills discussed above and nicotine replacement (or prescribing bupropion hydrochloride) discussed below, social support for cessation helps the smoker quit.2 Social support increases the smoker’s desire to quit, helps the smoker acquire the skills to become and remain abstinent, and reinforces actions that have been taken to quit smoking. The power of social support for quitting given by the clinician can be optimized by applying the concepts of the Transtheoretical Model of Change described above. While social support on an interpersonal level comes from family, friends and health-care providers, the power of a smoke-free environment to reinforce the message that not smoking is more acceptable than smoking should not be underestimated. NICOTINE REPLACEMENT The addition of nicotine replacement approximately doubles the efficacy of any particular smoking cessation intervention.2 Nicotine replacement is available as gum, transdermal patches, nasal spray, and inhalers. The patient’s preferences should be considered when selecting a nicotine delivery system. Karl Olaf Fagerstrom, for example, gives his patients a ‘‘grab bag’’ of the various delivery systems so that they can choose the one that they find most convenient and attractive (personal communication). The smoker should be advised to use enough replacement nicotine to keep cravings under control. Although many physicians are concerned that their patients may become addicted to nicotine replacement, it is this observer’s opinion that nicotine replacement is usually abandoned too quickly rather than used too long. It is helpful to keep in mind that smokers are addicted to nicotine long before they begin to use nicotine replacement devices, and some smokers may need nicotine replacement for years. Bupropion hydrochloride (Zyban姞), originally used clinically as an antidepressant, has also been found to be efficacious in the smoking cessation process.5 Although efficacy has been demonstrated in randomized clinical trials, the mechanism of action is not entirely clear. The Mayo Clinic Nicotine Dependence Center usually suggests starting bupropion hydrochloride at 150 mg daily for one week before the patient quits smoking and then increasing the dose to 150 mg twice daily for eight weeks. A history of seizures is a contraindication to the prescription of bupropion hydrochloride. Simultaneous use with nicotine replacement products increases efficacy. ^ 1999 Harcourt Brace & Co. Ltd
ACTIVISM AND LEADERSHIP It is inappropriate to believe that delivering smoking cessation interventions to one’s own patients in the clinical setting is sufficient to deal with the burden that tobacco places on individuals and entire populations. The root cause of widespread nicotine addiction – aggressive marketing of tobacco products to minors and young adults – cannot be ignored. Although the AHCPR report emphasized that each physician has an obligation to lead his or her organization to implement smoking cessation intervention systems,2 the panel’s conclusion that each physician must be active to prevent nicotine addiction was removed from the report in response to political pressure. While individual physicians have demonstrated exemplary personal leadership to counter the effects of nearly 50 years of tobacco industry lies and deception,7 activists in the State of California have led the way in reducing the per capita consumption of cigarettes in a defined population. Stan Glantz, on his list serve web site (http://www.smokescreen.org) suggests that the following lessons from California may be useful in other states. (Personal communication, Stan Glantz, February 5, 1999). E
E
E
An aggressive anti-tobacco advertising campaign combined with community-based programs that stress the need to create a smoke-free society can rapidly reduce tobacco use. A successful program is not simply directed at keeping kids from smoking; it strives to protect non-smokers from secondhand smoke and creates environments that facilitate smokers’ decisions to cut down or quit. The foundation of a successful campaign is the de-legitimization of tobacco use and de-normalization of the tobacco industry.
When the California program followed these principles, the rate of decline in tobacco consumption tripled and the rate of decline in smoking prevalence increased significantly.8 When the Governor Pete Wilson’s administration toned down, scaled back, and shifted the focus of the tobacco control program to children, progress slowed or stopped. Glantz emphasizes that young adults are the key population – for both the tobacco industry and the public health community. On the one hand, the tobacco industry is concentrating their marketing efforts on young adults to avoid criticism that they are targeting children but with clear recognition that young adults are the strongest role models for teens and young children. Young adults who smoke, by the very act of smoking, market tobacco use to children. On the other hand, young adults are open to pro-health messages because they are starting families (and are concerned about secondhand smoke), and they work in smoke-free environments. Young adults are a particularly important cessation target because quitting after only a few years of smoking avoids most of the health consequences of smoking.
^ 1999 Harcourt Brace & Co. Ltd
Glantz draws three critical lessons from tobacco control efforts in California: E E E
Non-smokers are as important an audience as smokers. The tobacco industry never gives up. The more effective the program, the more vigorously the tobacco industry and its allies will attack it.
As a corollary, the tobacco industry can always be expected to fight the implementation of tobacco control programs and, when that tactic fails, seek to subvert active programs by channeling them into unproductive activities such as concentrating solely on very young children. In 8 years, the California Tobacco Control Program has prevented 2 billion packs of cigarettes (worth $3 billion to the tobacco industry) from being smoked. This has resulted in teen smoking rates that are well below the increases that occurred nationally. It can be estimated that the program has prevented more than 14 000 heart attacks and strokes, deferred death for over 2500 individuals, and prevented low birth weight for over 10 800 infants. The $500 million in medical costs that were avoided from these causes of death alone amounted to more than the anti-smoking media and community programs cost. More detailed information about the California tobacco program will be available in a forthcoming book by Glantz and Balbach to be published by the University of California Press, California Tobacco Wars. SUMMARY Smoking cessation intervention is a critical skill for any physician, and the particular components that generate efficacy have been identified: skills building, social support for cessation, and nicotine replacement. The clinician who understands how to use the Transtheoretical Model of Change will be more successful in applying interventions and will find intervention more satisfying. However, no smoking cessation intervention can be considered complete unless there is a component of leadership and activism to set the agenda for tobacco control both in the clinic and the community. Literature cited 1. Doll R, Peto R, Wheatley K et al. BMJ 1994; 309: 901d911 2. Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 1996; 275(16): 1270d1280 3. Prochaska JO, DiClemente CC, Norcross JC. Am Psychol 1992; 47: 1102d1114 4. Pallonen UE. Prev Med 1998; 27: A29dA38 5. Hurt RD, Sachs DPL, Glover ED et al. N Engl J Med 1997; 337: 1195d1202 6. Jorenby DE, Leischow SJ, Nides MA et al. N Engl J Med 1999; 340:685d691 7. Hurt RD, Robertson CR. JAMA 1998; 280: 1173d1181 8. Pierce JP. Gilpin EA. Emery SL et al. JAMA. 1998; 280: 893d899
Evidence-based Cardiovascular Medicine (1999) 3, 4d5
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