THE SMOKING CESSATION CLINIC : The Lung Center Experience

1
THE SMOKING CESSATION CLINIC The Lung Center
Experience

• Dina V. Diaz, M.D.

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LUNG CENTERSTOP SMOKING CLINICSMOKING CONTROL
PROGRAM

• Clinic-based Self-Control Approach
• Est. July, 1987

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LCP Stop Smoking Clinic

• Objectives
• To provide help and support to the smoker who
  desires to quit smoking by means of a
  self-control approach
• To determine the success rate of the self-control
  method in smoking cessation

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LCP Stop Smoking Clinic

• Target population
• All smokers
• High-risk groups
• Heavy smokers
• Those with smoking-related diseases
• Those with urgent need to stop smoking to be
  acceptable for surgical treatment for disorders
  unrelated to smoking
• Pregnant women
• Those who engage in high-risk occupations
  (e.g. asbestos workers)

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LCP Stop Smoking Clinic

• Target population
• Special groups
• Opinion leaders
• Health professionals
• Sources of referrals
• Patients
• Physicians
• Institutions
• Organizations

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LCP Stop Smoking ClinicProcedure

• Initial Assessment
• Completion of Smoking Information Questionnaire
• Completion of Smoking Motivation Questionnaire
• Clinical history and P.E.
• Carbon monoxide breath test
• Spirometry
• Refundable deposit and nominal fee

Forfeited if patient drops out of program
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LCP Stop Smoking ClinicProcedure

• General Orientation
• Review of personal data of participant noting
  important points relevant to smoking
  cessation
• Explanation of results of Smoking Motivation
  Questionnaire

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LCP Stop Smoking ClinicProcedure

• General Orientation
• Discussion of program including options available
  
• Self-control approach
• Pharmacological method
• Acupuncture
• Hypnosis
• Group sessions
• Acupuncture Therapeutic and Research Center,
  Inc.
• Fr. Bulatao, Ateneo de Manila

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LCP Stop Smoking ClinicProcedure

• Carrying out treatment
• Establish goals of therapy
• Set a QUIT DATE
• Therapy contract for smoking cessation motivation
  by contractual commitment
• Behavioral counseling to provide coping
  strategies
• Provision of handouts/ manual

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LCP Stop Smoking ClinicProcedure

• Follow-up scheduling at regular intervals after
  first visit
• at 1 week
• at 2 weeks
• at 1 month
• at 3 months
• at 6 months
• at 1 year
• Treatment for relapse

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LCP Stop Smoking ClinicStaffing and Budget (Yr I)

• Physicians (4) P 48,000/ yr.
• Nurse/receptionist (1) P 12,000/ yr.
• Office supplies P 50,000/yr.
• Communications P 50,000/yr.
• Subtotal P 166,000
• 10 Contingency fund P 16,600
• TOTAL P 182,600
• Additional Staff
• Psychiatrist honorarium-based per visit/month
• Hypnotist and Acupuncturist referral-based to
  charge their own professional fees

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LCP Stop Smoking ClinicStaffing and Budget (gtYr
I)

• Physicians (2) P 48,000/ yr.
• Nurse/N.A. P 18,000/yr.
• Clerk/ receptionist (1) P 14,400/ yr.
• Social worker (1) P 16,800/yr.
• Psychologist/Hypnotist P 36,000/yr.
• Psychiatrist P 36,000/yr.
• Acupuncturist P 36,000/yr.
• Office supplies/miscellaneous P
  60,000/yr.
• Subtotal P 265,200
• 10 Contingency fund P 26,520
• TOTAL P 291,700

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LCP Stop Smoking ClinicSmoking Cessation Record

• Name______________________________ Patients
  No.________________
• Address ___________________________ Date of
  entry _______________
• Age_____ Sex_______
• No. of cigarettes/day ________________
• No. of years of smoking _____________
• Previous attempts to quit
• a) No. of times _____________
• b) Methods used _______________________________
  ______________
• Fagerstrom Index ______________
• Smoking-related diseases _______________________
  ______________________
• General condition Bad Average Good

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LCP Stop Smoking ClinicSmoking Cessation Record
Expired-air Carbon monoxide Date Value
1st Visit ____ ______ 3 months ____ ______
1 year ____ ______
Physicians Overall Assessment Poor Fair Good
Excellent Efficacy Side-effect Profile
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Smoking Questionnaire

• General Data
• Occupation
• Permission to smoke at work
• Age started smoking
• Cigarette consumption over the past year and how
  much this varies from day-to-day
• Type of cigarettes smoked filter-tipped, plain,
  hand-rolled
• Full brand of usual cigarette tar content, size
• Whether inhaled or not
• Others pipe, cigars consumption

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Smoking Questionnaire

• How enjoyable is smoking for you ?
• Extremely enjoyable
• Fairly enjoyable
• Slightly enjoyable
• Not at all enjoyable
• How unpleasant do you find it if you cant smoke
  for an hour or two ?
• Extremely unpleasant
• Fairly unpleasant
• Slightly unpleasant
• Not at all unpleasant
• Do you think you are addicted to smoking ?
• Extremely, fairly, slightly, not at all, dont
  know

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Smoking Questionnaire

• If you wanted to stop smoking altogether, how
  difficult would you find it ?
• Very easy, fairly easy, fairly difficult, very
  difficult
• When you wake up do you usually smoke before your
  first cup of coffee or tea ?
• YES or NO
• On occasions when you cant smoke or you havent
  got any cigarettes on you, do you feel a craving
  for one ?
• Never, hardly ever, occasionally, frequently,
  always
• Is the person who is most important to you a
  smoker ?
• YES or NO
• What does this person feel about your smoking ?
• Objects strongly
• Prefers if I dont
• Doesnt mind
• Encourages me to smoke

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Smoking Questionnaire

• About how many times have you tried seriously to
  stop smoking over the past 5 years ?
• Do you have any health problems which you think
  are related to your smoking ?
• If you succeed in stopping smoking altogether, do
  you think you will be healthier ?
• In the short-term
• In the long-term
• What is your main reason for wanting to stop
  smoking ?
• Your health
• The expense
• Its a dirty habit
• Not fair on other people
• Dont like being an addict
• Some other reason

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Smoking Questionnaire

• How much do you want to stop smoking altogether ?
• Very much indeed
• Quite a lot
• Not very much
• Not at all
• Have you been feeling more depressed than usual
  over the past 3 months ?
• What is your weight ?
• What is your height ?
• Are you worried about gaining weight if you stop
  smoking ?
• Do you expect to be under much pressure at home
  or at work over the next three weeks ?
• Do you think you will stop smoking for at least a
  year ?
• How did you find this center ?

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Smoking Motivation Questionnaire

• Examples of statements
• I get a definite craving to smoke when I have to
  stop for a while.
• Handling a cigarette is part of the enjoyment of
  smoking it.
• I smoke more when I am unhappy.
• Smoking helps to keep me going when Im tired.
• I feel I look more mature and sophisticated when
  smoking.
• I want to smoke most when I am comfortable and
  relaxed.
• I light up a cigarette when I feel angry about
  something.
• Responses Uncertain or not at all 0
• A little 1
• Quite a bit 2
• Very much 3

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Smoking Motivation Questionnaire

• Motivation for smoking
• Psychological image
• Hand-mouth activity
• Indulgent
• Sedative Score of 6 or more important
• Stimulation motivation for smoker
• Addictive
• Automatic
• Overall dependence score
• A score of 20 or more is high and suggest that
  you have to be very determined if you are to
  succeed in giving up smoking but it does not mean
  you will fail.

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LCP Stop Smoking ClinicContract for Smoking
Cessation

• After careful consideration, I ___________________
  _
• have decided to stop smoking.
• My quit date is ____________
• I am fully responsible for this decision and
  understand that my own commitment to stop is of
  primary importance.
• I will return to this clinic for my next smoking
  cessation appointment on
• ____________________
• Date
• If I need more help before that time, I will call
  _____________________ at _______________
• Signed _________________________________
• Patient
• Date ____________
• Signed _________________________________
• Doctor
• Date ____________

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Smoking Urge Diary
The first step in phasing out the smoking habit
is to learn as much as possible about what makes
you light up. This smoking urge diary will help
you learn which situations go hand In hand with
your urges to smoke. Everytime you get the urge
to smoke, take a moment to fill out the diary
before you light up. You will soon have a record
of your smoking habit. It will help you develop a
plan of action for avoiding your urges once you
have to quit.
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LCP Stop Smoking ClinicFollow-up Form

• Date
• Weight
• BP
• HR
• Gen Condition
• No. of cigarettes consumed since last visit
• Withdrawal symptoms, if any
• Coping strategies
• Expired-air Carbon monoxide
• Physicians assessment
• Plan
• Follow-up date
• Signature

• First visit
• From First visit
• First week
• Second week
• One month
• Three months
• Six months
• One year

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LCP Stop Smoking ClinicPatient Data

• First patient in August, 1987
• Evaluation done August, 1988
• Total Patients 243
• Average age 39.36 yrs.
• MaleFemale 6.15 1
• Civil status 61.31 married

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LCP Stop Smoking ClinicPatient Data

• Employment
• Employed 41.56
• Self-employed 27.16
• Occupation
• Professional, managerial, administrative 198/
  243
• Smoking allowed at work 95
• Mean age started smoking 17.63 yrs old
• Ave. no. of cigarettes smoked/day 23.44
  sticks/day
• Inhaled
• A lot 43
• Fairly 42

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LCP Stop Smoking ClinicPatient Data

• Enjoyment
• Extreme 31.40
• Fairly 53.72
• Cigars/ pipes 2-3
• Unpleasant without
• Extremely 35.68
• Fairly 35. 27
• Addiction
• Extremely 46.69
• Fairly 32.23
• Ease in stopping
• Very difficult 45.64
• Fairly difficult 41.07

• Craving
• Always 39.49
• Freq 26.05
• Occ. 27.31
• Most impt person smokes ?
• No 73.53
• Objects strongly 36.55
• Prefers dont 34.45
• Doesnt mind 23.95
• Encourages 3.78

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LCP Stop Smoking ClinicPatient Data

• No. of times tried to stop
• 5 26.44
• 2- 4x 33.88
• Once 27.27
• Never 12.39
• Longest time without
• lt 1 day 23.60
• 1-6 days 33
• 1-4 wks 16.74
• 1-3 mos 12.02
• Ave. Dependence score
• 13.83
• Ave. C.O. level
• 20.77

• Health problem ?
• Yes 65.97
• No 34.04
• Quitting will help your health
• In short term 67. 98
• In long term 92.07
• Main reason for quitting
• Health 201/243
• Desire to stop
• Very 76.76
• Quite 19.09

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LCP Stop Smoking ClinicPatient Data

• Depressed ?
• Not 35.49
• Slightly 30.73
• Quite 19.05
• Very 14.71
• Worried about weight gain?
• Not 55.18
• Slightly 23.23
• Fairly 12.03
• Very 9.54
• Undue pressure ?
• Not 27.84
• Slightly 30.38
• Quite 25.73
• Very 16.03

• Success in stopping ?
• Definitely 35.68
• Probably 59.03
• Prob not 4.40
• Def. not 8.81
• How did you find out about this center ? N 229
• Friend 52
• News/mag 119
• TV/radio 5
• MD 27
• Other 28

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LCP Stop Smoking ClinicSmoking Motivation (n 40)

• Psychological image 3 (7.5 )
• Hand-mouth activity 10 (25 )
• Indulgent 24 (60 )
• Sedative 24 (60 )
• Stimulation 20 (50 )
• Addictive 23 (58 )
• Automatic 12 (30 )

Average overall dependence score 15.82
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LCP Stop Smoking Clinic Previous Cigarette
Consumption, Duration of Smoking Abstinence,
Follow-up (n 40)

• Quit rate 99
• Success rate 5

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LCP Stop Smoking ClinicSelf-Control Approach

• Objective
• To provide help and support to the smoker who
  desires to quit smoking on his/her own by means
  of a self-control approach.
• Materials Self-help manual
• Program design
• Orientation to the program
• Enrolment to the program
• Physician advice on smoking cessation
• Provision of supplemental materials
• Follow-up monitoring

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LCP Stop Smoking Clinic
Freedom from Smoking (A Self-Help Manual)
LCP STOP SMOKING CLINIC FREEDOM FROM
SMOKING (A SELF-HELP MANUAL)
Adapted from American Lung Association Freedom
from Smoking for You and your Family
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LCP Stop Smoking ClinicSelf-Control Approach

• Physician advice on smoking cessation
• Introduction
• Basis of program need and relevance
• Review of risks of smoking
• Specific risks salient to patient based on
  history, family,etc.
• Major risks
• Personalize message
• Express own concern as a physician
• Connect risks to patients clinical condition

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LCP Stop Smoking ClinicSelf-Control Approach

• Physician advice on smoking cessation (contd)
• Ask Patient to describe his or her thoughts or
  feelings about quitting smoking
• Prior attempts
• Reasons for wanting to quit
• Self-estimate of willingness to quit at this time
• Projected problems in doing so
• Complete 3 steps
• Focus on smoking physicians concern and intent
  of advice
• Build confidence
• Contract for behavior change

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LCP Stop Smoking ClinicSelf-Control Approach

• Physician advice on smoking cessation (contd)
• Review simple plan for smoking cessation
• Monitor smoking patterns for a few days to one
  week to identify times of likely temptation
• Set quit date that is personally meaningful and
  fits with smoking pattern
• Try to break up familiar patterns of smoking
  while continuing regular levels of consumption
• Identify ways in which family members or friends
  can assist in efforts and recruit their
  assistance
• Make plans for rewarding self for achievement of
  sub-goals before and after cessation

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LCP Stop Smoking ClinicSelf-Control Approach

• Physician advice on smoking cessation (contd)
• Review alternative cessation resources in clinic
• Set plan for follow-up, such as
• Schedule follow-up visits from quit date at
• 1 week
• 2 weeks
• 1 month
• 3 months
• 6 months
• 12 months
• Call or contact by nurse or social worker if
  patient fails to come for follow-up
• Note in chart to review success at next routine
  visit

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LCP Stop Smoking ClinicGroup Support Program

• Objective
• To provide a group support program to smokers who
  want to stop smoking
• Guidelines Methodology
• Conduct of twice weekly sessions
• 10 to 25 participants with 1 group leader and 1
  assistant

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LCP Stop Smoking ClinicGroup Support Program

• Aim of the program
• To maximize the effectiveness of a broad-spectrum
  behavior modification procedure using an
  integrated sequence of instructions
• Three main phases
• Reduction of smoking
• Cessation of smoking
• Maintenance of non-smoking

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LCP Stop Smoking ClinicGroup Support
ProgramOutline of Sessions

• Session 1
• Session 2
• Session 3

• Understanding your smoking habit Part I
• Understanding your smoking habit Part II
• Cutting down your smoking habit
• Preparing to Quit
• QUIT DAY !
• Understanding Nicotine Addiction
• Health Benefits

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LCP Stop Smoking ClinicGroup Support
ProgramOutline of Sessions

• Session 4
• Session 5
• Session 6
• Session 7
• Session 8

• Group Support Relaxation Techniques
• Group Support Assertiveness Training
• Hypnosis
• Group Support Diet and Weight Control
• Group Support Stress Management
• Preventing Relapse Where do we go from here ?
• Group Celebration

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LCP Stop Smoking ClinicGroup Support Program

• Problem of keeping smoker in the program
• Require a deposit which is non-refundable if
  smoker drops out of the program
• Addition of a nominal fee to defray the costs of
  maintaining the program
• Problem of compliance
• Small group provided for social reinforcement
• Positive reinforcement for behavior which leads
  to non-smoking
• To enhance attractiveness of treatment
• To reduce premature termination of passive
  resistance

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LCP Stop Smoking ClinicGroup Support Program

• Reduction and termination of smoking obtained
  using techniques of
• Stimulus control
• Disruptive links between cigarette smoking and
  various internal and external events
• Follow-up sessions
• Two follow-up sessions one month apart
• Mailed questionnaires on 6th month and at 1 year

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LCP Stop Smoking ClinicGroup Support Program Data

• and freq. of sessions 4 q week
• Ave. of pts. per session 4 5 pts.
• Total or enrollees in a year 30 35 pts.
• Drop-out rate 70
• Success rate in a year lt 10

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LCP Smoking Control ProgramOther Components

• Self-control approach
• Group Support Program
• Model Hospital Program No Smoking
• Smoking Control School Program
• Smoking Control Industrial Setting
• Action on Smoking Awareness, Prevention and
  Control (A.S.A.P.)
• Smoking Cessation Workshops for Health care
  workers

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Thank you for your attention !