Behavior Change: The Example of Smoking Cessation

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[edit] Behavior Change: The Example of Smoking Cessation

Barrie J. Guise

Michael G. Goldstein

Lifestyle factors significantly contribute to more than half of the annual deaths in the United States. In addition, medical goals are closely linked to behavioral goals. Nevertheless, facilitating desired health behavior change among patients remains a challenging aspect of primary care.

Human behavior change has traditionally been the bailiwick only of behavioral scientists. In the early 1970s as human health problems became increasingly linked to behavior, collaborations among theorists and investigators in both behavioral psychology and medicine produced the interdisciplinary field of behavioral medicine.

Behavioral medicine's mandate is to apply the knowledge and techniques of behavioral and biomedical science to the prevention, diagnosis, and treatment of medical illness. Although they are critical to effective medical practice and compatible with the practical aspects of medical care, knowledge and skill in the formulation and treatment of health behavior problems have unfortunately been slow to find a prominent place in medical training, resulting in feelings of frustration and incompetence among many primary care physicians.

This chapter introduces the reader to the fundamental principles and techniques of behavioral medicine and then elaborates in detail, using smoking cessation treatment as an example.

[edit] FUNDAMENTALS OF BEHAVIOR CHANGE

Behavior changes that promote health range from increasing the frequency of some behaviors (e.g., exercise) to decreasing the frequency of others (e.g., cigarette smoking) to introducing new behaviors (e.g., home blood glucose monitoring). To accomplish behavior change, it is necessary to systematically formulate behavior as a target for intervention. Early behavioral scientists first described paradigms that applied the experimental method to the study of observable behavior, explained behavior in terms of controlled operations, and permitted the reliable prediction of behavior given particular environmental conditions.

The following very basic principles of operant and then classical conditioning are derived from that extensive literature and are borne out in everyday experience: (1) if behavior persists, it is being reinforced (e.g., eating tasty high-fat foods); (2) if behavior ceases, it either has not been reinforced or has been punished (e.g., noncompliance with ineffective medications or those with troublesome side effects); and reinforcement and punishment are defined by the effect each has on behavior, and not by whether each seems positive or negative to an outside observer. For example, although frequent hospitalizations due to noncompliance with an asthma regimen seem negative or like punishment, the avoidance of medication side effects operates on this behavior and acts as a reinforcer, although it is not "positive" per se. Classical conditioning consists of repeated pairings between unrelated experiences or stimuli, such that one thereafter cues the other. This principle accounts for most specific urges to smoke in habitual situations, for instance, with a cup of coffee or in a favorite chair.

In more recent years it has been asserted that cognitions (thoughts and beliefs) can be governed by the same principles as observable behavior and that motivation is an important mediating variable for human behavior. The health belief model^[1] asserts that an individual's beliefs about his or her vulnerability to the consequences of disease and about the likelihood that intervention will be protective are important factors in determining health behavior. More recently, the transtheoretic model of change^[2] proposes that an individual's motivation or readiness to change is an important factor in predicting the response to strategies designed to modify behavior and that individuals move through a series of stages of readiness to change: precontemplation (not yet willing to consider change), contemplation (ambivalent but considering change), preparation (intending to change imminently), action (actively attempting to change), and maintenance (attempting to maintain a change).

These models have important implications for the selection of interventions. For example, it stands to reason that an individual who is not yet willing to consider starting an exercise program might not make much use of specific instructions on how to begin exercising. This individual may benefit more from efforts to move him or her along to the contemplation stage, such as an effort to personalize a rationale for exercise. This implies that low motivation need not be an intractable barrier to change, but rather a legitimate target for change. Indeed, traditional learning paradigms are combined with motivational and often pharmacologic interventions to facilitate desired health outcomes.

[edit] BEHAVIOR CHANGE: CIGARETTE SMOKING

The beginning of this chapter has presented a brief exposure to the principles by which behavior may be formulated systematically in the day-to-day practice of medicine. The remainder of this chapter is devoted to integrating behavioral and biomedical principles and techniques to address perhaps the most important behavioral challenge in primary care: cigarette smoking. It is helpful to keep in mind that, with the exception of the specific pharmacologic therapies discussed in the upcoming sections, similar general ideas and approaches are applicable to other lifestyle challenges, such as diet and low physical activity.

[edit] Scope of the Problem

The Surgeon General has stated that smoking is the chief avoidable cause of death in our society. Annually, 3 million deaths are attributed to smoking worldwide. It is estimated that this number will rise to 10 million by the year 2025. Cigarette smokers have greater overall morbidity than nonsmokers, more restricted activity days, more bed disability days, more school and work absenteeism, and higher utilization of inpatient and outpatient services. An additional 53,000 nonsmoker deaths per year are attributed to the effects of environmental tobacco smoke.

Because the majority of smokers visit a physician at least once each year, primary care physicians can play a central role in reducing the morbidity and mortality associated with cigarette smoking. Although most primary care physicians report that they provide smoking cessation advice to all or almost all of their smoking patients,^[3] a recent population- based survey of patients reported that 51% of smokers were talked to about their smoking; 45.5% were advised to quit; 14.9% were offered help; 3% had a follow-up appointment arranged; and 8.5% were prescribed medication.

In a recent survey, more physicians rated smokers' lack of motivation as the most important barrier to smoking cessation.^[4] More than two thirds of this sample also reported that counseling about smoking is frustrating. These findings suggest that physicians feel especially unprepared and ineffective when faced with patients who are not yet ready to quit smoking. For some physicians these negative feelings are fueled by unrealistic expectations. Because even the most effective physician-delivered intervention results in 1-year abstinence rates of less than 25%, physicians become increasingly frustrated if they expect their efforts to produce abstinence rates of greater magnitude.^[5] This barrier may be overcome by helping physicians to develop more realistic expectations, by providing specific training in motivational and behavioral techniques, and by encouraging physicians to focus on intermediate outcomes, such as moving a patient who is not interested in quitting to the point of considering it. Strategies to address these barriers are discussed in both Assessment and Management.

[edit] Assessment

Biologic, behavioral, and psychologic factors all contribute to the initiation and maintenance of cigarette smoking. Therefore assessment must be designed to identify the specific elements corresponding to these areas for each smoker.

The principal goals of this assessment process are to (1) characterize the patient's level of motivation or readiness to quit smoking, (2) assess the severity of nicotine dependence, (3) assess the architecture of an individual's smoking habit, and (4) identify the psychiatric comorbidity that is likely to complicate treatment.

[edit] Assessing the Patient's Motivation to Quit.

Much of the frustration and time expenditure physicians experience in counseling smokers is due to a mismatch between the intervention used and the patient's level of motivation. The transtheoretic model of change described earlier can help physicians to assess and intervene more effectively and time-efficiently with their smoking patients. This model provides a way of characterizing different levels of motivation such that treatment can be stage-matched. Staging a smoker's readiness is accomplished by applying the answers to three questions in a simple algorithm (Fig. 57-1).

Figure 57-1 Stage of readiness algorithm.

Individuals at the precontemplation and contemplation stages, who may represent as many as 80% of current smokers seen in a typical medical practice, are not likely to respond to exhortations to quit smoking or interventions that are oriented to quitting, such as nicotine replacement. These patients need motivational interventions that increase awareness and help the individual to recognize the negative aspects of smoking (the cons) (see Management). Only about 20% of smokers who seek medical care are in the preparation stage and have taken steps toward quitting, such as making recent attempts to quit, delaying their first cigarette in the morning, or cutting down on the number of cigarettes that they smoke. These individuals are most likely to respond to interventions that will help them to successfully manage a subsequent attempt to quit, such as nicotine replacement, self-help manuals, behavioral skill training, and referral to a formal treatment program or group.

After individuals have quit smoking, a single question assesses their current stage: "How long ago did you quit smoking?" If the answer is less than 6 months, the patient is in the action stage. If the answer is more than 6 months, the patient is in the maintenance stage. Because smokers are very likely to relapse during the action stage, especially during the first few days and weeks after quitting, these individuals benefit from interventions that are designed to prevent slips and relapses (see Management).

[edit] Assessing the Level of Nicotine Dependence.

Smoking leads to the development of physical dependence on nicotine in the vast majority of smokers. Nicotine, the major psychoactive substance in cigarettes, has a wide variety of euphoriant, stimulant, anxiolytic, and antinociceptive effects involving multiple physiologic systems.^[6] Each of these effects contributes to nicotine's power as a reinforcer of smoking behavior. Moreover, nicotine produces a well-defined abstinence or withdrawal syndrome (Box 57-1),^[7] the avoidance of which maintains smoking.

Several strategies can assess a patient's level of nicotine dependence (see Box 57-2). Perhaps the most common measure of nicotine dependence is the Fagerstrom tolerance questionnaire (FTQ),^[8] a seven-item, self-administered form that identifies behaviors thought to reflect nicotine dependence (e.g., high smoking rate and brand nicotine level, smoking when ill or soon after awakening). Scores on the FTQ are related to withdrawal symptoms and the success of smoking cessation. The scale can be administered within several minutes and is easily scored. The time to the first cigarette in the morning, a specific item on the FTQ, appears to be an independent predictor of smoking cessation outcome. A response of "less than 30 minutes" suggests that the patient is smoking to control the withdrawal that results from overnight abstinence. In addition, individuals who smoke more than 25 cigarettes per day may be more likely to report withdrawal symptoms during abstinence than smokers consuming fewer cigarettes, although the evidence for this relationship is limited. The physician should ask about withdrawal signs and symptoms during abstinence in previous attempts to quit. Symptoms may also have occurred when the patient switched to a low-nicotine cigarette, or after the patient stopped using smokeless tobacco products or nicotine-replacement medication.

Although biologic tests of nicotine exposure (i.e., cotinine assays or expired alveolar carbon monoxide) provide objective measure of nicotine dependence, they are costly and time-consuming. These assays are neither feasible nor necessary for effective smoking cessation treatment in the clinical setting.

[edit] Assessing Smoking Architecture.

The fundamental principles of behavior change described earlier guide the physician's understanding of and then approach to the variables maintaining smoking for a given individual. Recalling that the effects of inhaled nicotine are reinforcing and immediate, and repeatedly paired with a wide range of situations, provides the key to long-term abstinence from cigarettes.

A useful assessment strategy is to make a detailed functional analysis of the situations and circumstances in which an individual patient smokes. Patients are simply instructed to monitor their smoking for a few days, keeping a log of the time of each cigarette, the situation in which smoking took place, their mood or affect, and their thoughts about the cigarette. The physician and patient review the self-monitoring record to make note of patterns that easily reveal frequent or powerful cues for smoking.

[edit] Assessment of Comorbidity.

A crucial step in assessment is to determine whether there is any evidence for psychiatric comorbidity. There is a strong association between smoking and other psychiatric disorders, especially depression, other substance-use disorders, schizophrenia, and anxiety disorders. The current existence or a history of any of these disorders is likely to make smoking cessation more difficult. Moreover, smoking cessation may precipitate the development of depressive symptoms in patients with a history of depression and may even precipitate a relapse of depression in susceptible patients. Smoking cessation does not appear to increase the risk of relapse of alcohol abuse or dependence.

The identification of psychiatric comorbidity has important implications for treatment. Although there are few research-based data on the treatment of nicotine dependence of patients with psychiatric comorbidity, identification, monitoring, and treatment of psychiatric comorbidity are important components of the management of such patients (Box 57-2) (see Management).

[edit] Management

After assessment is completed, interventions can be tailored to match each patient's needs. A step-care approach has been advocated for matching patients and treatments. The first step in management is to provide an intervention that is matched to the patient's stage of readiness to change. Since most patients are not ready for action, motivational interventions are usually most beneficial.^[9]

Once patients are ready to quit, a decision is made regarding the level, type, and intensity of smoking cessation treatment. This decision should be based on the patient's preferences, the level of nicotine dependence, the presence or absence of psychiatric comorbidity, the history of previous attempts to quit, and relevant behavioral parameters. Patients with low levels of nicotine dependence and little experience with quitting are most likely to respond to the lowest level of care: low-cost, minimal interventions, such as self-help, advice, and follow-up in the primary care setting. Those who have failed self-help approaches and those with high levels of nicotine dependence should be considered for the next level in care: brief face-to-face counseling and follow-up in the primary care setting or elsewhere (see Quitting Strategies).^[10]

In 1996, the Agency for Health Care Policy and Research (AHCPR) published an evidence-based clinical practice guideline^[11] for smoking cessation. See Box 57-3 for a summary of the recommendations of the AHCPR expert panel.

The AHCPR guideline stresses the pivotal role of primary care physicians and strongly recommends the implementation of office systems to identify and document smoking, the delivery of brief advice or counseling to all smokers at every visit, and the offer of nicotine replacement to all smokers who are committed to making a quit attempt. The recommendation to offer nicotine replacement therapy (NRT) to all smokers was based on evidence for the effectiveness of NRT when provided with only minimal adjuvant behavioral treatment and even when the smokers' levels of nicotine dependence were low.

The AHCPR panel also noted a dose-response relationship between the intensity of smoking cessation counseling and cessation outcome; brief advice increased quit rates by 20% (over no advice), 3 to 10 minutes of counseling increased rates by 40%, while 10 or more minutes of counseling more than doubled quit rates (Table 57-1). Counseling that utilized a problem-solving approach and provided personal support was found to be particularly effective.

Table 57-1 Smoking Cessation Rates for Various Intensity Levels of Person-to-Person Contact

✢Actual 95% lower confidence estimate equals 1.03.

Patients with psychiatric comorbidity, including other substance abuse, may require a specific treatment for their associated problem before, or concurrent with, treatment for nicotine dependence. These patients, as well as those who have failed despite repeated attempts to quit, are also candidates for more intensive, formal treatment programs.

Because practitioners of primary care have an opportunity to intervene with smokers repeatedly over time, results of the initial intervention can be reviewed at subsequent visits. During follow-up, patients who have not successfully quit smoking can be reassessed, can be provided with another intervention at the same level, or can be advanced to a more intensive intervention. The discussion on the management of smoking cessation concludes with a section on organizational resources and aids available to primary care physicians.

[edit] Matching Interventions to the Patient's Stage of Change.

[edit] Motivational Interventions.

It is important to remember that successful counseling of smokers often results in changes in level of readiness or motivation to quit and not imminent quitting. Nicotine dependence is a stubborn problem that often requires persistent yet empathic efforts to increase motivation before actual behavior change occurs.

As discussed earlier, motivation is an important mediator of behavior change. Patients in the precontemplation stage respond best to motivational interventions that help them begin to think about quitting smoking.^[12] Personalized information and feedback can raise smokers' awareness of the ways in which smoking is affecting their health, thus raising the cons of smoking. Pulmonary function tests and other direct physiologic evidence of smoking's health effects are useful components to feedback. Asking patients in the precontemplation stage to reflect on their feelings about smoking is another useful intervention. It helps to make empathic statements, such as "I know it may be hard to quit smoking," and supportive statements, such as "When you are ready to quit, I'm willing to help." Feelings of demoralization can be addressed by informing the patient that most smokers make several attempts to quit before they are finally successful.

For patients in the contemplation stage it is especially useful to explore the reasons for smoking (the pros), as well as other barriers to quitting, so that potential solutions for overcoming barriers can be discussed. For example, if a patient reports that she depends on smoking to help her to manage her weight, the offer and provision of alternative weight-management strategies may tip the balance of pros and cons toward a decision to quit smoking. If a smoking patient's spouse or other family member smokes, an offer to help both of them to quit may remove another barrier to taking action.

Providing a menu of options from which the patient may choose is another effective motivational tool. Patients who become chronically stuck in the contemplation stage may benefit from encouragement to take small steps toward action, such as cutting down the number of cigarettes they smoke, delaying their first cigarette of the day, or trying to quit for only 24 hours. These patients may also be willing to monitor their smoking to identify important barriers and triggers that can be reviewed at a subsequent visit.

Patients in the contemplation stage may express negative feelings or fears about quitting. Clarification and legitimization of their feelings and expressions of support and respect may help these patients to feel heard and understood. Statements such as "I'm glad that you're thinking about quitting" are especially useful, since they reinforce patients' interest in quitting. Even if patients do not decide to quit in the near future, these interventions may help them to feel more comfortable when talking to their physicians about smoking and to feel more receptive to future interventions.

[edit] Quitting Strategies.

When the patient is finally in the preparation stage, or ready for action, appropriate action-oriented strategies can be advised or prescribed (Box 57-4). Several reviews have described strategies in considerable detail for patients in the action or the maintenance stage.^[13][14] Useful interventions for patients in the action stage are listed in Box 57-4 and include setting a specific date with the patient to quit; writing a contract; providing self-help materials; suggesting use of over-the-counter (OTC) NRT; prescribing NRT, bupropion, or other pharmacologic adjuncts; teaching behavioral skills (e.g., self-monitoring, setting goals, self-reward, stimulus control, substituting alternative behaviors, relaxation exercises, coping skills training); and enhancing social support. Individuals are most successful when multiple cognitive and behavioral strategies are used when attempting to quit smoking. Encouraging patients to begin or to continue a program of regular exercise is another useful intervention for patients in the action or maintenance stage.

[edit] Follow-up.

Follow-up visits become especially important when patients are in the action or maintenance stage. Since the vast majority of patients relapse after attempted abstinence, follow-up visits can help patients to use relapse as an opportunity for learning. By exploring the circumstances that led to a return to smoking, the physician and patient can develop a revised plan that includes specific strategies to address the triggers that led to the relapse. It may become apparent that the patient experienced the development or exacerbation of an underlying psychiatric disorder. These disorders may require specific treatment or referral before the patient is able to successfully quit smoking.

At the follow-up visit the health care provider can praise the patient's efforts and reinforce the strategies that the patient used effectively. Praise and reinforcement are also useful to patients who are abstinent at follow-up. Anticipation of and planning for future problem situations and triggers for relapse are also beneficial.

[edit] Pharmacologic Interventions.

Pharmacologic agents are effective as interventions for smoking cessation, especially when used in conjunction with behavioral interventions. Although long-term abstinence depends ultimately on behavior change, pharmacologic agents are important because they minimize withdrawal and craving, making the time needed to decay the various learned aspects of the habit of smoking pass more easily. Our recommendations for use of pharmacotherapy are based on the AHCPR 1996 clinical practice guideline,^[11] the American Psychiatric Association's 1996 nicotine dependence guideline,^[15] and a recent review article that focused on advances in pharmacotherapy for smoking cessation since the publication of these guidelines.^[14] Use of NRT and bupropion, the only pharmacologic agents approved by the Food and Drug Administration (FDA) for smoking cessation, will be discussed here. The reader is referred to recent reviews for more detailed information about NRT and bupropion and for information about other pharmacologic interventions.^[14][16] Four forms of NRT have been approved by the FDA for use as aids to smoking cessation: nicotine gum, transdermal nicotine, nicotine nasal spray, and nicotine inhaler. Nicotine gum and transdermal nicotine are both available OTC and increase quit rates by 50% to 100%, even when administered with minimal or no adjuvant behavioral treatment. However, absolute smoking cessation rates are clearly enhanced when more intensive behavioral treatment is provided with transdermal nicotine and nicotine gum. There is limited information available regarding the efficacy of nicotine nasal spray and nicotine inhaler when these agents are administered with minimal behavioral treatment. Nicotine inhaler and spray are available by prescription only.

Choosing the form of NRT for an individual patient is based primarily on patient preference. This conclusion is based on the following evidence: (1) three of the four forms of NRT (transdermal patches, nasal spray, and inhaler) have very similar efficacies; (2) although the efficacy of nicotine gum is somewhat lower than the other three, this may be due to decreased compliance as well as improper chewing technique; (3) we are not aware of any published studies that have directly compared smoking cessation outcomes for different forms of NRT; and (4) there is no evidence to suggest that specific forms of NRT are more effective with subgroups of smokers. However, highly dependent smokers, as measured by the FTQ, benefit more from the 4 mg dosage form than the 2 mg gum.^[17]

Patient preferences for different forms of NRT relate to ease of administration (e.g., once-a-day administration for patch), differing side effect profiles (e.g., patch more likely to produce sleep disturbances; gum more likely to produce dyspepsia and dental problems; nasal spray more likely to cause rhinitis), onset of action (e.g., fastest for spray, slowest for patch), and sense of personal control over craving (e.g., least for patch). Recent evidence suggests that combined transdermal nicotine and nicotine gum may be more effective than either alone. See Boxes 57-5 and 57-6 for nicotine patch and gum guidelines.

Bupropion, an antidepressant with noradrenergic and dopaminergic activity, is the first FDA-approved nonnicotine drug treatment for smoking cessation and the only smoking cessation treatment available in pill. Results of clinical trials have demonstrated that bupropion is effective in promoting long-term smoking cessation when combined with brief counseling and is at least as effective as nicotine replacement. The dose of bupropion that is most effective for smoking cessation is 150 mg (of the sustained release [SR] preparation) twice-a-day. Medication is started 2 weeks before the quit day at 150 mg per day and is increased to 300 mg per day after 3 days. Recommended duration of therapy is 7 to 12 weeks after quitting. Longer term trials are currently being evaluated. Bupropion and transdermal nicotine may be used in concert, although the long-term benefit is not clear. The most common side effects of bupropion are tremor, rash, headache, and urticaria. Because bupropion may lower the threshold for seizures, it is contraindicated in patients with a history of seizures and should be used with caution in patients with a personal or family history of seizures, active alcohol or other substance abuse, or a history of head injury. However, no seizures were reported in any of the bupropion SR smoking cessation trials, which included a total of 1828 patients.

[edit] Referral to Formal Treatment Programs.

Referral to a formal treatment program is indicated only when the patient is highly motivated to quit and is willing to attend such a treatment program. Patients with high levels of nicotine dependence, those who have repeatedly failed to quit using self-help methods and brief counseling, and patients with psychiatric comorbidity are most likely to benefit from formal treatment. Formal treatment programs range from volunteer- led programs that combine group support with an introduction to behavioral quitting strategies, to multidisciplinary outpatient and inpatient treatment centers that can provide intensive behavioral and pharmacologic treatment. The success of formal treatment programs with carefully selected, motivated smokers ranges from 15% to 40%.

[edit] Organizational Resources and Aids.

Kottke, Solberg, and Brekke^[18] described the organizational components and systems that are essential to the delivery of effective and consistent counseling in primary care office settings. Because research has demonstrated that physician-delivered smoking cessation interventions are most likely to be effective when physicians are routinely reminded to intervene with all smoking patients with the use of chart stickers or similar reminder systems, these systems should be integrated into all office practices.

Resources for patients, physicians, and office staff members are important tools that enhance the capacity of health care providers to provide information and advice. Self-help manuals for smoking cessation are effective and are available through voluntary agencies.

[edit] REFERENCES