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Clinical Trials and Patient Education for Smoking Cessation

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Clinical Trials and Patient Education for Smoking Cessation

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  1. Clinical Trials and Patient Education for Smoking Cessation Maureen George PhD RN AE-C FAAN University of Pennsylvania School of Nursing

  2. http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_15.pdf

  3. 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

  4. 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

  5. Characteristics of Dependence Clinical Assessment Physical Assessment Tolerance Useful effects Withdrawal symptoms Drug seeking • Morning smoking behaviors • Smoke > 1 ppd • Sneak cigarettes • Smoke when ill • Time intensive • Conditioned response Know health hazards

  6. 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

  7. Educational interventions must be targeted • Gender • Those most resistant to quitting • High-risk smokers • Menthol cigarettes • Benefits of cessation at any time

  8. Benefit to quitting smoking at any age

  9. 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

  10. The 5 A’s • Ask at every contact • Advise to quit • Assess willingness • Assist in making quit plan • Arrange f/u

  11. 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.”

  12. 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 • Provide feedback that creates discrepancy, • Clarify goals • Actively help • 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 (and direct confrontation).

  13. 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.

  14. 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;

  15. 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

  16. The 5 R’s: Treating patients who are not ready to quit

  17. Clinical trials @ www.clinicaltrials.gov 259 open trials Testing in all patient groups Pregnancy Prisoners Expectant Latino fathers Overweight Veterans American Indians Substance users Mental health disorders Adolescents Medical conditions • Most are trials of products • Several seek to see what quit rates are when treatment is free • CAM • Exercise • Relaxation • Yoga • Hypnotherapy • MBSR • Auricular acupressure

  18. Clinical trials @ www.clinicaltrials.gov Testing at all POC Testing all approaches Behavioral Drug Technology-assisted Web-based, Mobile phones: SMS support IVR Individual vs. group Quit and win contests Testing messages specific for literacy levels • EDs • Pre-admission • Inpatient • Outpatient