Impediment Profiling for Smoking Cessation: Breaking Down Barriers to Behavioral Goals

1. Impediment Profiling for Smoking Cessation:Breaking Down Barriers to Behavioral Goals David L. Katz, MD, MPH, FACPM, FACP Director, Prevention Research Center Yale University School of Medicine Art & Science of Health Promotion Conference Las Vegas, NV March 23, 2006

2. Key References- • Katz DL. Behavior modification in primary care: the pressure system model. Prev Med. 2001;32:66-72 • Katz DL, Boukhalil J, Lucan SC, Shah D, Chan W, Yeh MC. Impediment profiling for smoking cessation. Preliminary experience. Behav Modif. 2003;27:524-37 • O'Connell M, Lucan SC, Yeh MC, Rodriguez E, Shah D, Chan W, Katz DL. Impediment profiling for smoking cessation: results of a pilot study. Am J Health Promot. 2003;17:300-3 • O'Connell ML, Freeman M, Jennings G, Chan W, Greci LS, Manta ID, Katz DL. Smoking cessation for high school students. Impact evaluation of a novel program. Behav Modif. 2004;28:133-46 • More papers in press

3. Modifiable Behaviors & Health • The leading “causes” of death are the “results” of risk factors • Nearly 50% of all deaths in the US each year are premature and related to modifiable behaviors • Tobacco, Diet, and Physical Activity patterns are the leading causes of premature death • McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-12 • Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-45

4. What Behavior Is • The “best” choice under prevailing circumstances/conditions

5. The Challenge of Change • Moving out of a desired or valued pattern • Moving into a rejected, or unknown pattern

6. Leading Theories • Theory of Reasoned Action • Health Beliefs Model • Social Cognitive Theory/Self-efficacy • Social Learning Theory/Locus of Control • Transtheoretical Model/Stages of Change & Processes of Change Institute of Medicine. Health and Behavior: the Interplay of Biological, Behavioral, and Societal Influences. National Academy Press. Washington, D.C. 2001

7. Reasoned Action • Consideration of pros and cons • Choice based on options and values

8. Health Belief Model • Must believe he/she is susceptible • Must perceive the potential seriousness • Must believe that benefits outweigh the costs and inconvenience • Must believe he/she is capable • There must be a “cue to action”

9. Transtheoretical Model • Stages of Change • Processes of Change

10. Stages of Change • Precontemplation • Contemplation • Preparation • Action • Maintenance/Lapse • Termination Prochaska J, DiClemente C. Psychotherapy: Theory, Res, Pract. 1982;19:276-288

11. Processes of Change • Consciousness Raising • Dramatic Relief • Self-Reevaluation • Environmental Reevaluation • Self-Liberation • Helping Relationships • Counterconditioning • Contingency Management • Stimulus Control • Social Liberation Prochaska JO, Redding CA, Evers KE. The Transtheoretical Model and Stages of Change. In: Glanz K, Lewis FM, Rimer BK (eds). Health Behavior and Health Education. Theory, Research, and Practice. 2nd edition. Jossey-Bass, Inc. San Fancisco, CA. 1997.

12. Getting There Requires the Right “M/O” • M = maximizing motivation • O = overcoming obstacles • Katz DL. Behavior Modification in Primary Care: the Pressure System Model. Prev Med. 2001;32:66-72

13. Motivational Interviewing General Principles: • 1) express empathy / acknowledge ambivalence • 2) develop discrepancy • 3) avoid argumentation • 4) roll with resistance • 5) support self-efficacy • 6) encourage social contracting Miller WR. Addict Behav. 1996;21:835-42; Rollnick S. Int J Obes Relat Metabl Disord. 1996;20suppl1:s22-6

14. Increase Physical Activity Maintain Current Activity Level Advantages Advantages Weight loss Easy Better health Comfortable Avoid risk of injury More energy Avoid sweating Disadvantages Hard work Disadvantages No weight loss Limited time No health benefits Unsure how Possible weight gain Decision Balance for Physical Activity. Cells in the balance show some hypothetical entries.

15. Motivation can be the sound of one hand clapping…

16. Overcoming Resistance • Acknowledge obstacles • Convert obstacles into challenges/opportunities • Identify/surmount universal barriers • Identify/surmount patient-specific barriers

17. The Inspiration for IP- • How stone many walls with no windows or doors does it take to impede your progress?

18. Tailored Interventions for Smoking Cessation (TISC)

19. Study Team: PREVENTION RESEARCH CENTER David L. Katz, MD, MPH, FACPM, FACP Project PI Meghan O’Connell, MPH Project Coordinator Sean Lucan Research Assistant YSM*4 Ming-Chin Yeh, PhD Research Associate Wendy Chan, MPH Data Analyst *Yale Medical School

20. PURPOSE • To establish a reliable means of identifying and quantifying the diverse impediments to smoking cessation in an individual • To demonstrate that smoking cessation interventions tailored to individual impediment profiles increase one and two- year quit rates

21. BACKGROUND • Cigarette smoking is the leading cause of preventable death in the U.S. • The literature suggests that there are 7 commonly identified impediments to smoking cessation: nicotine dependence; stress; anxiety; depression; chemical codependency;concern about weight gain; and the presence of at least one smoker in the household

22. METHODS Survey Design • Comprehensive screening tools were developed to identify and quantify impediments by fusing items from existing and newly developed questionnaires • Validated instruments were located for nicotine dependence, stress, anxiety, and depression. • Multi-item questionnaires for assessing chemical dependency and concern about weight gain were developed from surveys used in clinical practice. • A single, direct question used to assess the presence of household members who smoke

23. Long Impediment Profiler: Fusion Of Instruments

24. Recruitment Inclusion criteria: -smoking history > 1 year -current smoking > 15 cigarettes per day -resident of Lower Naugatuck Valley, CT. -> 18 years of age Exclusion criteria: -current use of nicotine replacement products -allergy to study medications, history of seizures -participation in other cessation program -uncompensated medical problems

25. SUBJECTS

26. Intervention Applications • Nicotine dependence • Subjects meeting criteria on the Fagerstrom scale were given bupropion, for a total of 12 weeks started 2 weeks prior to target quit date • Subjects received transdermal nicotine replacement therapy for 10 weeks starting on the quit date (2 weeks into program) • Co-morbid chemical dependencies • -Subjects meeting CAGE score criteria were evaluated by an addictions specialist and referred to a Chemical Dependency Program

27. Intervention Applications, Cont. • Anxiety • Subjects meeting criteria on the Beck Anxiety Inventory received the anxiolytic, buspirone, for 8 weeks. Therapy started 2 weeks prior to quit date. • Depression • Subjects meeting Beck Depression Inventory criteria were referred for psychiatric evaluation, with treatment on the basis of professional discretion. • Smoking by household member • Subjects with family/household members who smoke were invited to family group counseling dinner meetings.

28. Intervention Applications, Cont. • Stress • Subjects meeting criteria on the Simple Stress and Tension Test were enrolled in a stress- management program consisting of yoga, guided relaxation, and meditation conducted weekly throughout the year-long program. • Weight management • Subjects meeting “Smoking Situations Scale” criteria enrolled in four 1-hour dietary counseling sessions. • Organized walking groups met 3 times per week for 20 minutes, for a period of one month. • Discounted membership to YMCA for subsequent 3 months.

29. RESULTS N=19 Percentage of subjects with impediments:

31. Results, Cont. • No significant difference in the proportions of participants that quit smoking between males and females at the significance level of 0.05. (p=0.9) • Insufficient evidence to suggest that any single impediment predicts quit status

32. Participation/intervention Ratings

33. Conclusions • This novel approach resulted in 42% and 26% quit rates at one and two years respectively, a significant improvement over best quit rates reported in literature. • Targeting therapies for each of the 7 commonly reported impediments to quitting smoking may have resulted in the high quit rates achieved in the study.

34. Conclusions, Cont. • Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right. • The further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted.

35. Worksite Study- To replicate the promising results of a pilot study using an approach to smoking cessation termed “impediment profiling” in the worksite setting

36. Background • Cigarette smoking is the leading cause of preventable death in the U.S.1 • The CDC’s Community Guide to Preventive Services recommends smoking cessation interventions be made available2 • Worksites as an important venue3 • Potential benefits to both employees and employers3 • Novel “Impediment Profiling” methods applied in a community hospital setting

37. Methods PLANNING • Community hospital/PRC partnership for planning and implementation • administration, human resources, outpatient psychiatry, dietary, volunteer services depts. • Promotion of program for manager/supervisor buy-in • Hospital/PRC resource sharing

38. Methods (cont’d) RECRUITMENT • All smoking employees were invited to participate via internal email, flyers, informational sessions for each department, information provided with employee benefits package, letters sent to all employees

39. Methods (cont’d.) IMPLEMENTATION • Use of Impediment Profiling (IP) instrument (previously validated) for barrier identification • Assignment to interventions as indicated by measurement scales: • NRT; treatment for anxiety/depression; dietary counseling and PA for weight gain prevention; stress reduction; family support groups; referral to treatment of chemical co- dependencies

40. Methods (cont’d.) • Specific intervention components were… • Self-reported quit status was verified with measurement of carbon monoxide (CO) concentration in expired air • Smoking cessation was defined as CO reading of < 10ppm.

41. Results • 55 enrolled • 4 dropped out prior to study commencement, resulting in sample of 51 employees • 88% of participants had previously attempted to quit • Stages of Change survey indicated subjects were in the following stages at baseline: 8% precontemplative 69% contemplative 23% action

42. Subjects

43. Percentage of subjects with impediments:

44. Participation

47. Conclusions • This study achieved a 39% one-year quit rate, replicating pilot findings indicating that IP and tailoring of interventions results in a dramatic improvement over quit rates reported in the literature • Seventy-seven percent of participants were in either the precontemplative or contemplative “stage of change” at enrollment, suggesting that providing individualized assistance may be highly effective at increasing/maintaining motivation to quit

48. Conclusions (cont’d) • Independent of quit rate, profiling impediments to smoking cessation served to identify otherwise ignored health problems meriting treatment in their own right • Further study of impediment profiling as a smoking cessation adjunct in larger, longer, and randomized trials is warranted

49. Conclusions (cont’d) • The study demonstrated the feasibility of applying IP methods in a worksite setting • Hospitals in particular are ideal settings for smoking cessation interventions. By capitalizing on existing resources and involving stakeholders, creative programs can be implemented to benefit the entire workforce

50. I have a dream… • Impediment profiling for all: web-based • Mapping individualized paths to behavior change • Application to eating/weight control…