Nicotine Dependence: Initiation, Cessation and the Process of Change

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Nicotine Dependence Initiation, Cessation and
the Process of Change

• Carlo C. DiClemente, Ph.D.
• University of Maryland Baltimore County
• Department of Psychology 1000 Hilltop Circle
• Baltimore, MD 21250
• E-mail diclemen_at_umbc.edu
• http//www.umbc.edu/psych/habits
• www.mdquit.org

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C. Everett Koop, M.D.
Cigarette smoking is the chief, single avoidable
cause of death in our society and the most
important public health issue of our time.
U.S. Surgeon General, 1981-1989
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Smoking Prevalence Among U.S. Adults (gt18)

• YEAR Overall Males Females
• 1965 42.4 51.9 33.9
• 1970 37.3 44.1 31.5
• 1980 33.2 37.6 29.3
• 1990 25.5 28.4 22.8
• 1995 24.7 27.0 22.6
• 2000 23.3 25.7 21.0
• 2004 20.9 23.4 18.5

MMWR 11.11.05
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SMOKELESS TOBACCO

• Smokeless is less prevalent but creates similar
  dependence on nicotine
• Contains 28 cancer causing agents
• Estimates are that about 3 of adults are
  smokeless tobacco users (2005 NSDU)
• Two leading brands are Skoal (28) and Copenhagen
  (22). New one SNUS
• Different Product Similar Process of Change
  (Severson)

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51.4
49.7
Men
Women
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Lung Cancer Incidence California vs. Rest of
U.S. 1988-2003
U.S. minus CA (SEER)
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California
21!
SEER includes 14 cancer registries from across
the U.S.
American Cancer Society, CA Division and Public
Health Institute, CA Cancer Registry, California
Cancer Facts and Figures 2007, September 2006.
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The Big Picture - 2004

• 90.2 million ever smokers (42.4 of pop with gt100
  lifetime cigarettes)
• 45.6 million (50.6) former smokers
• 44.5 million people smoking the U.S.
• 36.1 million smoked every day
• 14.6 million of these (40.5) stopped smoking for
  one day in past 12 mo trying to quit
• 8.3 million smoked some days

MMWR 11.11.05
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Population VS IndividualPerspectives on Cessation

• Individual Level
• Successful one year unaided quit rates range from
  3 to 6
• Many smokers (40-47) attempt to quit
• Multiple unsuccessful quit attempts the norm
• High interest in quitting but low uptake of help

• Population Level
• Smoking cessation one of the most successful
  health behavior changes in our history
• Dramatic reduction in of smokers over past 40
  years
• Over 50 of living ever smokers are quit

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A Personal Journey

• The journey into and out of nicotine addiction is
  a personal one marked by
• Biological, psychological and social risk and
  protective factors
• Social Influences (peers, media, tobacco
  companies, policies, current events)
• Personal choices and decisions
• A process of change that is common and a path
  that is unique for each smoker

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How Do People Change?

• People change voluntarily only when
• They Become interested and concerned about the
  need for change
• They Become convinced that the change is in their
  best interests or will benefit them more than
  cost them
• They Organize a plan of action that they are
  committed to implementing
• They Take the actions that are necessary to make
  the change and sustain the change

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Stage of Change Tasks

• Awareness, Concern,
• Hope, Confidence
• Risk-Reward Analysis Solid Decision to Change
• Commitment Creating An Effective/Acceptable
  Plan
• Adequate Implementation and Revising of Plan
• Integration of new behavior into Lifestyle

• Precontemplation
• not interested
• Contemplation
• considering
• Preparation
• Getting Ready
• Action
• Initial Change
• Maintenance
• Sustained Change

DiClemente. Addiction and Change How Addictions
Develop and Addicted People Recover. NY Guilford
Press 2003. DiClemente. J Addictions Nursing.
2005165.
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The Transtheoretical Model of Intentional
Behavior Change
STAGES OF CHANGE PRECONTEMPLATION ?
CONTEMPLATION ? PREPARATION ? ACTION ?
MAINTENANCE
PROCESSES OF CHANGE COGNITIVE/EXPERIENTIAL BEH
AVIORAL   Consciousness Raising Self-Liberatio
n Self-Revaluation Counter-conditioning Envir
onmental Reevaluation Stimulus
Control Emotional Arousal/Dramatic
Relief Reinforcement Management Social
Liberation Helping Relationships CONTEXT OF
CHANGE 1. Current Life Situation 2. Beliefs
and Attitudes 3. Interpersonal Relationships 4.
Social Systems 5. Enduring Personal
Characteristics MARKERS OF CHANGE Decisional
Balance Self-Efficacy/Tempta
tion
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Theoretical and practical considerations related
to movement through the Stages of Change
Motivation Decision-Making
Self-efficacy
Precontemplation Contemplation
Preparation Action Maintenance
Personal Environmental Decisional
Cognitive Behavioral Concerns
Pressure Balance Experiential
Processes (Pros
Cons) Processes Recycling
Relapse
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Addiction and Change

• Both acquisition of and recovery from an
  addiction require a personal journey through an
  intentional change process
• The journey is influenced at various points
• by factors identified in etiological models
• by personal decisional considerations and
  choices
• Personal choices are influenced by and in turn
  influence genetic, developmental,
  characterological, and social forces
• There is an interaction between the individual
  and the surrounding risk and protective factors
  that involves a Process of Change

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THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Sustained Cessation
Dependence
RECOVERY
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Stage Based Epidemiology
PC
M
PC
C
M
C
A
A
PA
PA
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Maryland Adult Tobacco Survey (MATS)
2000 MATS
2002 MATS

• 27,192 participants
• 45.2 Male
• 72.9 White
• Mean Age 42.4 years
• 74.9 Ever Married
• 89.1 HS grad

• 16,596 participants
• 43.7 Male
• 76.7 White
• Mean Age 45.8 years
• 71.3 Ever Married
• 86.5 HS grad

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Stage of Change for Smoking Cessation in the
Maryland Adult Tobacco Survey (MATS)

• Participants were classified into 5 Stages of
  Smoking Cessation
• Precontemplation Current smokers who are not
  planning on quitting smoking in the next 6 months
• Contemplation Current smokers who are planning
  on quitting smoking in the next 6 months but have
  not made a quit attempt in the past year
• Preparation Current smokers who are definitely
  planning to quit within next 30 days and have
  made a quit attempt in the past year
• Action Individuals who are not currently
  smoking and have stopped smoking within the past
  6 months
• Maintenance Individuals who are not currently
  smoking and have stopped smoking for longer than
  6 months but less than 5 years

DiClemente, 2003
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Stages of Change for Ever Smokers
2002 MATS
2000 MATS
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Table 1 Stages of Change for Current Smokers
2000 MATS
2002 MATS
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Stages of Change Ethnicity

• 2000 MATS
• Precontemplation
• 33.4 vs. 42.7
• Contemplation
• 20.5 vs. 15.7
• Preparation
• 19.7 vs. 13.7
• Action
• 4.3 vs. 6.0
• Maintenance
• 22.0 vs. 21.9

• 2002 MATS
• Precontemplation
• 28.8 vs. 38.3
• Contemplation
• 18.1 vs. 15.3
• Preparation
• 22.3 vs. 13.7
• Action
• 6.4 vs. 7.5
• Maintenance
• 24.5 vs. 25.2

Non-White White
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Cyclical Model for Intervention

• Most smokers will recycle through multiple quit
  attempts and multiple interventions.
• However successful cessation occurs for large
  numbers of smokers over time.
• Keys to successful recycling
• Persistent efforts
• Repeated contacts
• Helping the smoker take the next step
• Bolster self-efficacy and motivation
• Match strategy to patient stage of change

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Challenges Along the Smokers Journey to Cessation

• Becoming convinced of the need to quit NOW
• Making a firm decision supported by strong
  emotional and rational reasons and values
• Creating a strong commitment and a viable,
  effective plan
• Making quitting a priority among multiple demands
• Managing the initial withdrawal and early threats
  to give up on the effort and return to smoking
• Integrating abstinence from smoking into daily
  routines and lifestyle
• Being willing to keep trying despite setbacks and
  to learn from relapses how to get cessation right
  

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Special Problems and Populations for Cessation

• Access to effective treatments
• Proliferation of alternative approaches
• Challenges of subgroups of smokers
• mentally ill
• low SES
• adolescents
• women

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STAR Project

• 304 participants
• 76 persons with Schizophrenia
• 24 persons with Affective D/O with Psychosis

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Important Considerations for SMI

• Substance abuse and smoking by individuals with
  severe mental illness is ubiquitous.
• It is not clear if individuals with schizophrenia
  can access and utilize a similar process of
  change as other drug abusing individuals.
• It is also not clear whether individuals with
  Schizophrenia differ from other non psychotic
  individuals in terms of their profiles on process
  measures identified in the Transtheoretical Model

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SUMMARY OF A RECENT STUDY

• Measures of readiness and other process variables
  demonstrated reliability and construct validity
  among SMI patients who smoke.
• Schizophrenia patients appear to be using the
  same or similar process of change in managing
  their smoking cessation as other non SMI smokers
• Although neurocognitive deficits among patients
  with schizophrenia interfere with access to some
  higher order cognitive functions and may modulate
  the process, these patients appear to access and
  use the intentional process of change as
  described in the TTM in managing and recovering
  from substance abuse, in this case nicotine
  dependence.

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Increasing Population Quit Rates The
Opportunity and the Problem

• Greatest hope for HP2010 goal lt 12 adult
  prevalence
• Enormous potential to save lives, reduce costs,
  reduce health disparities
• 70 of nations 44.5 million adult smokers want
  to quit and over 40 of the SMI smokers
• 40.5 make a serious quit attempt each year
  (NHIS, 2004)
• Fewer than 5 succeed
• Most attempt to quit on their own, without
  effective treatments

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The Consumer Demand Roundtable

• Aim Identify and catalyze innovative strategies
  for increasing demand for and use of
  evidence-based tobacco cessation products and
  services --- particularly in underserved
  low-income and racial/ethnic minority populations

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Consumer Demand Roundtable Participants
Roundtable Members David Abrams, PhD, NIH OBSSR
Linda Bailey, JD, MH, NAQ Consortium Matt Barry,
MPA, Center Tobacco Free Kids Amanda Graham, PhD,
Brown University David Graham, Pfizer Karen
Gutierrez, Global Dialogue Pablo Izquierdo, MA,
Elevacion Ltd. Katherine Kemper, MBA,
GlaxoSmithKline Tim McAfee, MD, MPH, Free
Clear Myra Muramoto, MD, MPH, U. Arizona
Joachim Roski, PhD, MPH, NCQA Saul Shiffman,
PhD, U Pittsburgh Victor Strecher, PhD, MPH,
HealthMedia, Inc. Susan Swartz, MD, MPH, Maine
Medical Ctr. Frank Vocci, PhD, NIDA Dianne
Wilson, SC African-American Tobacco
Control Expert Advisers Elizabeth Barbeau,
Dianne Barker, Sean Bell, Bill Blatt, Mary Ann
Bright, Peter Coughlan, John Hughes, Gary
Giovino, Danny McGoldrick, John Pinney, Connie
Revell, Dawn Robbins
Planning Committee Carlo DiClemente, PhD UMBC
(Chair) C. Tracy Orleans, PhD, RWJF (Co-Chair)
Todd Phillips, MS, Acad. Educational
Development Elaine Arkin, RWJF Stephanie Smith,
PhD, MPH, Princeton/RWJF Kay Kahler Vose, MA.
Porter Novelli Rajni Laurent Sood, MA, Acad.
Educational Dev. Major Funders/Advisers ACS
Bettina Lanyi CDC Corinne Husten, MD, MPH Ann
Malarcher, DrPH, Karen Siener, MPH Legacy
Foundation Amber Hardy Thornton, MPH, CHES,
Cheryl Healton, DrPH , Bill Furmanski, MPH, Helen
Lettlow, PhD NCI Cathy Backinger, PhD NIDA
Frank Vocci. PhD OBSSR Patty Mabry, PhD, Brad
Wibel, PhD RWJF Marjorie Paloma, MPH, Joseph
Marx
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What is a Consumer?

• A person who has the power to buy, to choose from
  among options, to demand service, to decide, and
  to manage their choices and lives
• Individuals with an array of interests, values,
  tastes, opinions, attitudes and intentions
• A valued commodity to those who offer products
  and services
• Not just an alternate term for client or patient

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Why Do We Need Consumer- Centered Care for
Individuals who Smoke?

• They have choices about services
• They have to make informed choices about
  treatments (especially as the options increase)
• They have to comply with any treatment
• They are in charge of their personal process of
  change

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The Competitions Getting Stiffer
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Smokers are very concerned about
Percent of baseline smokers (ages 25 years)
Assessing Hard Core Smoking Survey
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Smoking helps
Percent of baseline smokers (ages 25 years)
Assessing Hard Core Smoking Survey
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Smokers Beliefs that May Impede Quitting -
United States, 2004/2005
Source Assessing Hard Core Smoking Survey (ages
25 years) n 1,000
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Only one-third of smokers correctly report that
patches are less likely to cause a heart attack
than cigarettes...
Cummings KM, Hyland A, Giovino GA, Hastrup J,
Bauer JE, Bansal MA. Are Smokers Adequately
Informed About the Health Risks of Smoking and
Medicinal Nicotine? Nicotine Tobacco Research
20046(Supplement 3)S333-S340.
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A Consumer-Centered Perspective

• Critical Shifts in Perspective from
• Pathology to Problems
• Pulling or Pushing to Persuasion
• Patient to Partner
• Provider to Facilitator
• Outcomes to Options
• Management to Motivation Marketing
• Reactive to Proactive Care
• Examples

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Going To Where The Smokers Are Brief
Counseling/Medication
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Highlights from Roundtable Discussions

• Reframe the cessation process  -- quitting as a
  journey, coaching vs.. counseling, NRT
  misconceptions, story-telling 
• Establish a seal of approval for proven
  products and services
•  
• Find new ways to market cessation
  products/services to underserved low-income and
  racial/ethnic minority populations
•  
• Find new ways to "design for demand" -- to
  make proven products/services more appealing and
  engaging (involve consumers, apply IDEO design
  process)
•  
• Build ongoing relationships with smokers (and
  their supporters) to reach them before, during,
  and beyond their quit journey 

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Highlights from Roundtable Discussions (cont)

• Establish databases of smokers and reconnect
  with them periodically --"viral marketing
•  Improve surveillance of quitting and treatment
  use what gets measured gets changed
• "Connect the dots"
• Link multiple different treatment products and
  services (quitline, medication, counseling,
  on-line)
• Take better advantage of policy changes
  (e.g., clean indoor airs laws, tobacco tax
  increases, coverage expansions) 
• Increase demand among employers, insurers and
  health plans the meta-consumers
• Find ways to embed and refine innovations in
  existing work -- opportunistic innovations,
  prototypic successes, early wins 
•  

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New York City
Coordinated policies and actions can stop the
nation's leading epidemic. The increase in the
cigarette tax, implementation of the Smoke Free
Air Act, our nicotine patch distribution program,
and public education about the health risks
associated with tobacco have prevented literally
tens of thousands of premature deaths." -
Commissioner Thomas R. Frieden, MD, MPH
NYC Department of Health and Mental Hygiene
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Etiology of Addictions
Conditioning
Social Influences
Genetics
Abuse
Personality
Initial Use
Self-Regulated Use
Physiology
Coping/Expectancies
Dependence
Environment
Reinforcement
All of these factors can have arrows to initial
experience and then to any or all of the three
patterns of use. Most could have arrows that
demonstrate linear or reciprocal causality as
well
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THE STAGES OF CHANGE FOR ADDICTION AND
RECOVERY
ADDICTION
Dependence
PC
C
PA
A
M
PROCESSES, CONTEXT AND MARKERS OF CHANGE
PC
C
PA
A
M
Sustained Cessation
Dependence
RECOVERY
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2000 Maryland Youth Tobacco Survey (MYTS)

• Secondary data analyses of the Maryland Youth
  Tobacco Survey (MYTS, 2000)
• Classroom-based survey, administered throughout
  Maryland
• Participants were public school students (N
  47,839), between the ages of 12 and 18 years
• The majority of the sample was Caucasian (69)
  and over half were Female (52), with a median
  age of 14 years

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All adolescents were classified into Stages of
Smoking Initiation by Level of Experience

• Level of Experience is analogous to prevalence
  measures with
• Never Smoked Inexperienced
• Smoked Less than 6 days Exposed
• Smoked 6 days Experienced
• Youth were classified according to their Stage of
  Smoking Initiation using
• Lifetime Smoking
• Ever smoked
• Future Intentions
• Smoke in next year?
• Current Smoking
• of days smoked past 30 days
• Duration of Current Smoking
• How long smoked current rate?

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Table 1. Distributions of Stage of Smoking
Initiation Level of Experience
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Logistic Regressions

• Using 2000 MYTS data, Logistic Regressions were
  estimated for both the Stages of Smoking
  Initiation Level of Experience
• 3 Key Risk Factors from 3 Domains of Influence
  were selected
• Behavioral
• Would you ever use or wear something that has a
  tobacco company name or picture on it such as a
  lighter, t-shirt, hat, or sunglasses?
• Attitudinal
• Do you think young people who smoke cigarettes
  have more friends?
• Intention
• If One of Your Best Friends Offered You a
  Cigarette, Would You Smoke It?

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Table 4. Odds-Ratios of Stages of Smoking
Initiation and Level of Experience for Intention
Risk Factor Accept Cigarette Offer from Best
Friend
plt.001
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Table 3. Odds-Ratios of Stages of Smoking
Initiation Level of Experience for Attitudinal
Risk Factor Smokers Have More Friends
plt.001
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Distribution of Stages of Smoking Initiation by
Wave School Status
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Adolescent Smoking in Maryland Stage Status /
Transitions
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PREVENTION OF INITIATION OF ADDICTION
PC - C
C - PA
PA - A
A - M
ALREADY AFFLICTED
AT- RISK PREVENTION
POPULATION PREVENTION
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THE MARYLAND RESOURCE CENTER

• The Maryland Quitting Use and Initiation of
  Tobacco (MDQuit) Resource Center is dedicated to
  assisting providers and programs in reducing
  tobacco use among citizens across the state.
• Our mission is to link professionals and
  providers to state tobacco initiatives, to
  provide evidence-based, effective resources and
  tools to local programs, to create and support an
  extensive, collaborative network of tobacco
  prevention and cessation professionals, and to
  provide a forum for sharing best practices
  throughout the state of Maryland.
• WEBSITE www.MDQuit.org PHONE [phone]
  FAX [phone]

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THE MARYLAND QUITLINE

• 1-800-QUITNOW is up and running in the State of
  Maryland!
• 1-800-QUITNOW/1-800-784-8669
• Maryland Smokers can now call 1-800-QUIT-NOW to
  get information about quitting smoking. This FREE
  service is available to non-smokers as well who
  are looking for information for a family member,
  a loved one, or even a patient or client.
• Calls to 1-800-QUIT-NOW are answered by
  well-trained persons who are there to improve a
  smoker's chances of successfully quitting
  smoking.

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Fax Referral Program

• Fax to Assist is located at web
  site where there is on-line training and
  certification for HIPAA-covered entities
• Providers can refer their patients or clients
  (who wish to quit, preferably within thirty
  days), to the Maryland Tobacco Quitline
• Tobacco users will sign the Maryland Fax Referral
  enrollment form during a face-to-face
  intervention with a provider (e.g., doctor's
  office, hospital, dentist's office, clinic or
  agency site)
• The provider will then fax the form to the
  Quitline. Within 48 hours, a Quit Coach makes
  the initial call to the tobacco user to begin the
  coaching process

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Opportunities and Innovations

• Explore new technologies to provide support and
  individualized feedback
• Get health care providers to ask and assist
• Explore how to use current and new
  pharmacological aids
• Use new motivational strategies and skill
  building treatments
• Focus on health and well-being and teachable
  moments
• Focus on subpopulation needs (women, mentally
  ill, adolescent smokers)