Transcript WAC_SMOKING_FINAL_REV_POSTING

Clinical Trials and Patient
Education
for
Smoking
Cessation
Maureen George PhD RN AE-C FAAN
University of Pennsylvania
School of Nursing
http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_15.pdf
• Number of new smokers is
unchanged
– Few start after age of 25
– No change in the lowest income groups
• 36% of 20-24 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
Clinical
Physical
Dependence
Assessment
Assessment
• Morning smoking
behaviors
• Smoke > 1 ppd
• Sneak cigarettes
• Smoke when ill
• Time intensive
• Conditioned response
• 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
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•
•
•
•
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
• 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
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 trials @
Testing
in
all
www.clinicaltrials.gov
259 open trials patient groups
• Most are trials of
products
– Several seek to
see what quit rates
are when treatment
is free
– CAM
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•
•
•
Exercise
Relaxation
Yoga
Hypnotherapy
• Pregnancy
• Prisoners
• Expectant Latino
fathers
• Overweight
• Veterans
• American Indians
• Substance users
• Mental health
disorders
• Adolescents
• Medical conditions
Clinical trials @
Testing www.clinicaltrials.gov
at all
Testing all
POC
approaches
•
•
•
•
EDs
Pre-admission
Inpatient
Outpatient
• Behavioral
• Drug
• Technologyassisted
– Web-based,
– Mobile phones:
SMS support
– IVR
• Individual vs. group
• Quit and win
contests