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Average Loss of Life

Tobacco robs an average of one-quarter century of life. One half of all regular smokers who start in their teens will eventually be killed by the habit. A-5 35-69 20-25 years are taken off the smokers life when compared to non-smokers. P. 20
The Hazards of Smokers and the Benefits of stopping. 8-3-00 11th World Conference on Smoking and Health Richard Peto.

One-third if all smokers will die prematurely.Treating


,Tobacco Use and Dependence,p.1,2000

Death Rates

Ages 35-69
(2/3) 2 out of 3 deaths of males age 35-69 is due to tobacco.

Age 70-79
1 out of every 2 deaths are smoking related

Death Rates

Age 80+
Smokers substantially exceed non-smokers in premature death
PA 10-Mortality from smoking. Developed countries 1950-2000 Oxford Press, 1994.

Reason Number 1
More than fifty years had elapsed since the inception of the 5 Day Plan. Only minor revisions had taken place. Knowledge about tobacco had increased exponentially.

Reason Number 2

Research was beginning to question the credibility of the accuracy of the presentations and of the 5 Day Plans effectiveness.

Five-Day Plan Evaluation

Dr. Itirvonen 1984, U of Oulu, Finland

Length of Program
Too Short Suitable Too Long
Course M 40.3 F - 42.3 59.7 57.7 0.0 0.0

Sessions M 1.9 F 0.9

93.9 94.5

4.2 4.6

P. 95 Leo Hirvonen (1984) U. of Oulu, Smoking Cessation 5 Day Plan. Finland. Act A U. Series D. Medical 23

Course Changes
1. 2.

3.
4. 5.

Prolongation of the course More intensity after treatment Smaller groups for discussion Improved quality of films Improved psychological guidance
P. 114 Finland 5DP

Vulnerability of Relapse Percentage


Group Total Up to 1 week Male 565 29.9 Female 578 31.3 50% Relapse first month.
Attendance

2-4 19.5 21.6

>6 mo. 31.2 22.7

1-2 x 87 1-4 x 32 5 x 786


P. 106 Finland 5 DP

74 52.6 21.8

10 18.5 20.9

.5 11.7 33.2

Greatest relapse related to fewer sessions attended.

Relapse Circumstances
Males % Females %

Work Place Home Social Contacts Visit Restaurants Holiday A long idle Normal situations Exceptional Alcohol
P. 107 Finland 5DP

24.7 10.7 24.2

18.4 17.9 28.6

4.5 9.6 6.2 20.2

6.6 4.6 13.8 8.2

Longer Programs
For her doctoral dissertation in the 1980s, Joyce Lin studied four Smoking Cessation Clinics. She found: 1 the more sessions attended and the higher the proportion of prescribed intervention received, the better the chances one had of stopping smoking. P. 79

Longer Programs - 2
2 The longer period of time spread over more weeks produced better results. P. 80 Smokers had a longer exposure to change process.

Multiple Clinics Evaluation

Joyce Lin, UCLA

Clinics
Clinics
1.

Smoke no more

Fee $275.00

Sessions 8

Scripts=Howard
2. 3.

4.

HMO ACS 5 Day Plan

$30/60 $10.00 Free

8 4 5

Short vs. Longer Program


# of Weeks Success Rate

# of Sessions 1 2 3 4 5 5 Day 5 ACS 2 2 HMO 5 2 1 Scripps 1 2 2 2 1

21% 36 % 45 % 74%

Extended Support Increased Intervention


# Maintained Recidivist Abstainers

Scripps HMO ACS 5DP

50 5 (10%) 81 14 14 9 (64%) 0

8 (16%)

37 (74%)

13(16%) 23(28%) 45 (55.5%) 5 (37.5%) 3 (21.4) 5 (35.7) 6 (42.9)

Higher Rate of Success, P. 50 Joyce Lin Dissertation,UCLA, 1985 (Maintained=smokers

Evaluation

of Smoking Cessation Methods-1985-1978-1985 USDHHS A Report on the Strategies to Control the Use of Tobacco in the U.S.-2000 USDHHS

1990 2000 A Report on the Strategies to Control Use of Tobacco in the U.S.
One concept emerges from evaluation of the various clinics presented in chapter 7, the more extensive the program, the more likely it is to be successful. Programs with a greater number of sessions, professionals rather than volunteer leaders and more extensive follow up and maintenance support show better results.

Treating Tobacco Use and Dependence USDHHS 2000

There is substantial evidence that intensive interventions have higher success rate than less intensive.p.37 There is a dose-response relation between counseling intensity and cessation success.p.38 The evidence suggests a dose-response relation between number of sessions and treatment and efficacy. P.49

Treating Tobacco Use and Dependence-2000


Multiple Clinicians involvement increase abstinence rate. P.60,61 Multiple formats increase abstinence rate-group counseling as well as individual, proactive telephone work.Ibid Multiple means of communication increase success Pamphlets,videos.mass media, computer programs, internet self-help sites. P 62 Tobacco Use and Dependence-2000

Number of Sessions
Number 0-1 2-3 4-8 >8

RR 1.0 1.4 1.9 2.3

Abstinence 12.4 16.3 20.9 24.7

Tobacco Use and Dependence p.60- 2000

RR= Relative Rate of Success

Time + Plus Intensity


Although the major focus of this research ir to show that both quality of the intervention and quantity of time spent between the Doctor and the smoker is most effective, the principles are equally true of group intervention. Time plus intensity equals abstinence.

Brevity vs. Longevity

Another problem associated with many quit programs is their ineffectiveness due to brevity, they do not last long enough to allow clients to shift long practiced smoking behaviors to non-smoking alternatives. The more intensive the program, the greater number of sessions, the more professional the servers the more extensive the follow up and maintenance the better the results.

The Biochemical Reason for Lengthening the Program


Nicotine Addictive components of tobacco nicotine In 1988 the surgeon generals reported for the first time: Tobacco is addictive It is one of the most addictive substances used by humans. Nicotine is 6-8 times more addictive then alcohol of the people who use tobacco 95-100% will become addicted. P. 9
SGR. JAMA 252:2874, 1984.

In a teen survey, when asked how many would be smoking five years from now, 1% believed they would 13% believed they might be 5 years later in actuality 90% were still smoking.

Withdrawal Symptoms
Withdrawal effects are the most intense for about a month after cessation and Are the major motivating factor for the user to continue. Hughes, Arch. Of

Gen. Psychiatry, P. 19, 43: 2890294, 1986.

Why is Nicotine So Potent and Addictive?

Major characteristics of addiction according to the Am. Psychiatric Assn.

1. Compulsive

The users experience the most irresistible urges. After regular use the smoker is no longer free to start and stop at will. It is so persistent that one or more efforts to stop is unsuccessful. It is so pervasive in nature that every organ and every cell is addicted.

2. Psychoactive

Induces change in the brain causing alteration in mood, feeling, thinking and perception. Sustains repetitive self-administration by virtue of its re-enforcing effects. Rewards and strengthens the behavior. Deceptive it may take 20 years for major harm to be experienced. Versatility it can be a sedative or a stimulant, depends on administration. Frequency 73,000 puffs per year per pack Speed of action nicotine hits the brain in 7-10 seconds, provides immediate reward.

3. Tolerance
Diminished responsiveness to successive administration. Larger amount are often taken than originally intended.

4. Withdrawal
The drugs power is measured by the strength of withdrawal symptoms. The drugs strength is often measured by predictable symptoms within an hour of discontinuance. The drug provides immediate punishment for disuse.

5. Relapse
Nicotine addictions--- permanent resumption can occur at anytime or anywhere before death. Ex-users are one cigarette away from re-addiction Relapse is a process not an event.

6. Its Easy
Its available everywhere Its affordable for everyone Its acceptable to many and legal for all Its like a disease.

The Five Rs of Motivation


In Education: Reading Writing Arithmetic
In Cessation: Relevance Risks Rewards Roadblocks Repetition

1. Relevance
Identify Personal Reasons for Quiting: 1. Health 2. Family 3. Work 4. Social 5. Friends 6. Prior Quitting Experience

2. Risks
Identify the potential negative consequences of continuing to smoke. Acute Risks - Shortness of breath - Exacerbation of asthma - Harm to fetus - Impotence - Infertility - Increased serum CO 2 levels

Long Term Risks


Heart attacks Stroke Cancers of lung, oral cavity, larynx, pharynx, esophagus, pancreas, bladder, cervix COPD Chronic bronchitis and emphysema Long term disability

Environmental Risks-ETS
Increased Lung Cancer of nonsmoking family members Increased Low-birth weight babies Respiratory infections Increased SIDS deaths Increased Heart Disease among family members

#3. Rewards
Identify potential rewards of cessation: Improved health Food will taste better Flowers will smell better Increased savings Higher self-esteem Set a good example for children House, car, clothes are fresher

Rewards
Have healthier babies and children No worry about exposure to others Feel physically better Perform more efficiently physically Reduced wrinkling and aging of skin

# 4. Roadblocks
Identify barriers to quitting: Withdrawal symptoms Fear of failure Fear of weight gain Lack of family or peer support Depression Enjoyment of smoking

5. Repetition
It takes most people several attempts of quitting to succeed So what if you fail once? Try again!

USDHHS Treating Tobacco Use and Dependence, June 2000 p.31-33

Profile of a Recidivist Develop strategies to deal with their situation


1. Inability to resist social pressure


Evaluation of Smoking Cessation Methods P. 119

2. Inability to cope with negative stress.


P. 119

3. Home alone 44% relapse at home 19% at work. 4. Most relapsed in the evening. 5. Most negative effects related to recidivism are: anxiety, anger, depression and frustration.

Profile of a Recidivist Strategies to deal with his/her situation 6. Exposure to alcohol - social drinking. Use of alcohol and coffee increased relapses P. 119 7. Exposure to Smoking.

Breathe Free Evaluation


Aug. 1987 960 questionnaires mailed to Directors in 60 conferences of smoking cessation programs 589 responses. 2. Program Preferences Breathe Free 61.2% 5 Day Plan 27.5% Other 11.3% Two years after intervention
1.

Breathe Free Evaluation LLU, 1988 P. 10

Sequence of Sessions
8 sessions 2-5-1 Follow sequence Modified
Number of Sessions Adequacy Too Few Adequate 15.5% 70.0%
P. 19, 20 Breathe Free Evaluation

71.9% 28.1%

Too Many 14.6%

Usage of Breathe Free Discussion Group


Yes
36.9% No

44.1% Sometimes 45.1%


P. 23 Breathe Free Evaluation

Satisfaction with Breathe Free Material


Yes No Personal Plan Booklet 97% 3% Scripts very or quite satisfying 92.6% Followed Scripts - Exactly Partially Health Professionals 16.2% 83.8% Ministers 29.4% 70.6%
Breathe Free Evaluation P. 23-25

Nicotine Dependence

In the US and the UK 75-80% of smokers want to stop. One-third have made at least three serious attempts to stop, but only 45% succeed. Before age 60 many die before they stop. Of smokers who have a heart attack 70% are smoking again within a year-38% while still in the hospital. P. 426-1994, 9th
World Conference

Highly Addictive Nature of Tobacco

Withdrawal effects, the worst of which last about a month, are a major motivation for continuing to use tobacco.

Hughes. archives of Gen. Psychiatry P. 19. 43: 289-294. 1986

Reasons For Relapse


Lack of motivation 63% Women gaining weight 34% Men Other illness, physical problems 14% An evaluation of a smoking withdrawal clinic (5 day
plan) Sept. 1979. Vol. 68 J.

Women may have greater problems due to depression, fear of weight gains, hormonal cycles. P.91 Treating Tobacco
Use and Dependence-2000

Relapse
Relapse

is not a failure, but a step in the process of learning to abstain from tobacco.

P. 438, 1994. 9th World Conference

People may attempt to stop smoking by many different methods.


Any method which is successful both legally and ethically is appropriate, but several have proven to be more effective. The handout - questionnaire methods of cessation will give you guidance. At this time we will discuss five of the most successful way to aid in the cessation process.

1.

Cold Turkey

Setting a date and time and stopping all nicotine administration.

2.

Nicotine Fading

Systematically reducing the number of cigarettes smoked, switching brands, or changing to a lower tar and lower nicotine brands.

3.

Nicotine Gum

A nicotine replacement program which allows the person to control nicotine dosage by the length of time chewing the gum. This may be helpful for the patient for whom skin sensitivity to the patches is a problem. Available without a prescription. Evidence for success is not very positive.
P. 83 Review and Evaluation of Smoking Cessation Method. 1985 USDHH 5

4.

Nicotine Patches.

Another nicotine replacement product which allows a measured degree of nicotine through the skin. As the program progresses the amount of nicotine is lowered and finally you are weaned away from the nicotine. Available without a prescription.

5. Anti-depressant medication.

Known chemically as Bupropionhydrochloride (HCI) and in the United States as Zyban. It's a prescription medicine recommended to use for seven to twelve weeks. Use of this medication allows the smoker to develop strategies of psychological and chemical problems of addiction while reducing their intake of nicotine via the cigarette or other types of tobacco use. Zyban reduces the urge to smoke before the nicotine withdrawal begins to take effect. Zyban can have complications for some users and may interact abnormally with certain medications.

6. Hypnosis.

(Not effective) There is little evidence that hypnosis is effective in smoking cessation. P. 42 R & E of SCM,
1985. There is insufficient evidence to support hypnosis as an effective treatment in smoking cessation.

.p.68 Treating Tobacco Use and Dependence-2000

7. Acupuncture

(Not effective) Low quit rates P. 48 R &


E of SCM, 1985. (Rapid and intensive smoking)

The

evidence does not support the efficacy of Acupuncture as a treatment for tobacco dependence.
P.67 Treating Tobacco Use and Dependence-2000

8.

& E of SCM, 1985.

Aversion

Techniques have largely failed. P. 75 R

Rapid

and continued Smoking may constitute a health risks without medical supervision.
P.67 Treating Tobacco Use and Dependence-2000

Pharmacotherapies For Tobacco Cessation

Kicking the nicotine dependency completely is inevitable if the drug addiction and the tobacco side effects are to ever be eliminated. However, there is some research which seems to demonstrate a significant number of tobacco users, (smokers, chewers or sniffers ) can reduce their withdrawal symptoms and increase their success rate by choosing one of the following nicotine delivery systems in conjunction with behavioral modification programs and or Zyban a non-nicotine intervention.

We suggest one of three therapies if they can begin and use them completely. Before the smoking cessation program begins or if the user has not been able to stop tobacco use by the third session of BreathFree. It is important to note that a new nonsmoker (ex-smoker) will be most successful long-term when most all aspects of the smokers life are replaced by healthy nonsmoking behaviors. This will best be accomplished by attending behavioral change classes.

Pharmacological Therapies for Smoking Cessation


Type-Duration
Nicotine Inhaler up to 6 months

How Used
Bring inhalant to mouth when an urge hits.

Dosage
6-16 cartridges per day

Nicotine Spray 3months, then taper

Every 1-2 hours, take deep 8-40 breath, spray into nostrils doses/day and exhale through mouth

ACS A Smokers Guide JAMA 6-28-2000, Vol. #24, p. 3250.

Pharmacogical Therapies for Smoking Cessation - 2


Type-Duration
Nicotine Gum 2-6 months

How Used

Dosage

Chew briefly, repeat up to 20 as needed. Absorbed pieces/day in the mouth. 2 or 4 mg. Apply patch to skin. 4 wks. Steady dose delivered 21 mg/24hr. through skin. 2 wks. 14 mg/24 hr. 2 wks. 7 mg/24 hr.

Nicotine Patch

Pharmacological Therapies for Smoking Cessation - 3


Type-Duration
Bupropion Zyban wks.

How Used
For 3 days 1 pill Then 2 pills/day

Dosage
start 2 before quitting, then for 7 to 12 wks

ACS A Smoking Guide, JAMA 6-28-2000, Vol. 283 #24 P. 3250

Pharmacological Therapies for Smoking Cessation - 4


Type-Duration Avg. Reactions Cost/Mo
Inhaler Local irritations Do not use with asthma or allergies. Nasal Irritations. Do not use with asthma or allergies. $160.00

Spray

$140.00

Gum

Mouth $100.00 Soreness, Dyspepsia $120.00 JAMA, 6-20-2000, Vol. 283 #24 ACS A Smoking Guide.

Pharmacological Therapies for Smoking Cessation - 5


Type-Duration Avg. Reactions Cost/month
Patch Local skin Reaction Vivid Dreams $90.00 - $120.00

Zyban

Insomnia $90.00 - $110.00 Dry mouth Contraindications history of seizures, eating disorders, pregnant, breast feeding, mao inhibitors

Reference same as before.

Breathe Free Success Rate


Success Rate % of Conductors <50 % 10.6 % 61-70% 20.3 % 71-80% 24.2 % 81-90% 27.3 % 91-100% 16.9 %

P. 19 Breathe-Free Evaluation-Loma Linda University 1992

Loma Lindas Success Rate

The Researchers at Loma Linda University Center for Health Promotion conducted the Breathe-Free Program eleven times during this year. They monitored each of the participants for one full year after the completion of each program of eight sessions. A person was not considered a participant until the end of the second session (sign up) and all dropout were included after the second session in the tabulation of successes and failures.

Loma Lindas Success Rate

The researchers at Loma Linda conducted and evaluated eleven programs during the year of study and found with a professional team their success rate jumped from 42% (the rate of the various conductors in the field) to 61 % at Loma Linda University.

The Bad News

Twenty-five percent of all Americans still smoke. Tobacco use is the chief avoidable cause of illness and death and is responsible for 500,000 deaths in the U.S,A. annually. Smoking is a known cause of heart disease, cancer, stroke, emphysema, COPD,Complications in pregnancy,
p. 7 Treating Tobacco Use and Dependency-2000

Smokings attributable cost in medical care was 50 billions dollars Cost of decreased productivity and`forfeited earning was 47 billion.

Encouragement

One half of all people who have ever smoked have quit. p.60
Treating Tobacco Use and Dependence-2000

Seventy percent of smokers try to quit at least once during their lifetime . Forty-six percent try each year, thats 17 million people. P. 9 Ibid

This means there are thousands of smokers who need to stop and will at sometime in their lifetime.