438 - Smoking Cessation Update, Physical Inactivity, Self-Compassion

From the Literature 

1)  Best Evidence for Smoking Cessation 

Treating tobacco addiction can feel like something we know already but given how prevalent it still is and how much misery it causes, it is prudent to keep up to date. 

A recent narrative (non-systematic) review of systematic reviews (I know, it’s confusing) in JAMA covers the available therapies and assembles the guidelines and best practices for helping our patients quit. Here are the highlights: 

·         This review included 30 systematic reviews, 12 recent influential RCTs, and 7 guidelines. 

·         Tobacco addiction involves both learned behavior and physical tolerance to nicotine. 

·         Over 2/3 of smokers want to quit eventually, but only 20% in the next 30 days. 

·         Look for “teachable moments” – tobacco-related illnesses, procedures, or hospitalizations – to intensify your efforts at smoking cessation counseling. 

·         The best predictors of significant addiction are the overall number of cigarettes smoked daily, and whether the patient has a morning, “eye-opener” cigarette. Other factors include earlier age of starting, a comorbid psychiatric or other substance use disorder, another smoker in the house, little social support for quitting, and a low level of self-confidence in their ability to quit. 

·         Nicotine replacement therapy (NRT) is best prescribed as patches PLUS a more rapid-acting form of nicotine as needed (gum, lozenges, inhaler) for breakthrough cravings. Relative risk for combined vs. single agent was 1.25; 95% CI, 1.15-1.36. 

·         Varenicline’s black box warning about neuropsychiatric effects was REMOVED in 2016 after the EAGLES trial (a comparative effectiveness RCT) showed no increased risk of side effects vs. bupropion, NRT or placebo. 

·         The EAGLES trial showed the effectiveness rates of medications in weeks 9 through 24 of therapy to be: 21.8% (varenicline), 16.2% (bupropion), 15.7% (nicotine patch), and 9.4% (placebo). 

·         Weaker evidence suggests that any combination of smoking cessation therapies is well-tolerated and more effective that single therapies, but because of conflicting data, it is recommended to do this only if a patient has failed single therapy. 

·         Giving smoking cessation therapy to a patient who is interested in short term reduction prior to a longer-term goal of cessation works well (NNT ~ 4 with varenicline, RR ~ 1.25 with NRT). 

·         Look for cytisine, a drug used in other countries with an effect comparable to that of varenicline, to be evaluated for approval in the US soon. 

·         E-cigarettes, as covered in a past Take 3, have some evidence that they can help, but are still not recommended for smoking cessation given the lack of standardization of concentrations and ingredients, concern about relapse to cigarettes, and lack of long-term data. 

·         The data for counseling suggests intensive counseling works better, but some counseling is better than none (Range of quit rates 6-14%). Cognitive behavioral

·         therapy, skills building, problem-solving, and medication adherence counseling are important components. 

·         The evidence for effectiveness of motivational interviewing is actually a bit mixed, but most guidelines still recommend it for physician counseling. 

·         The Five As approach is recommended as an overall strategy for clinicians to organize their management of tobacco dependence: 

o   Ask – whether and how much your patient smokes 

o   Advise – that smoking is unhealthy, and they should quit 

o   Assess – their readiness to quit 

o   Assist – them with counseling and medications as desired 

o   Arrange – referrals as needed AND follow up with them to demonstrate the importance of quitting 

John’s Comments:

Insurance coverage for all these smoking cessation treatment options is still too variable, but there is a lot that we can do. Reviewing data like this can help address the therapeutic inertia we feel in the face of such a persistent problem.  

Reference:  

·         Rigotti NA, Kruse GR, Livingstone-Banks J, Hartmann-Boyce J. Treatment of Tobacco Smoking: A Review. JAMA. 2022;327(6):566-577. Link 

From the CDC and the BRFSS

2)  Adult Physical Inactivity Prevalence in the US

The Behavioral Risk Factor Surveillance System (BRFSS) is the nation’s premier system of health-related telephone surveys that collect state data about health-related risk behaviors, chronic health conditions, and use of preventive services.  Established in 1984, the BRFSS now completes more than 400,000 adult interviews each year from persons in all 50 states as well as the District of Columbia and three U.S. territories.

The CDC recently published the combined data from 2017-2020 BRFSS surveys regarding physical inactivity among US adults.  In this case, the question for the survey was a very simple one:  “During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?”

Overall, the prevalence of physical inactivity was 25.3%.  When the data was broken out by race/ethnicity, non-Hispanic Asian adults (20.1%) had the lowest prevalence of physical inactivity outside of work followed by non-Hispanic White (23.0%), non-Hispanic American Indian/Alaska Native (29.1%), non-Hispanic Black (30.0%), and Hispanic adults (32.1%).  In terms of geographic location, the map below captures trends across the country.  The lowest prevalence of inactivity was 17.7% (Colorado), and the highest prevalence was 49.4% (Puerto Rico).

Mark’s Comments:

This survey measured ANY deliberate physical activity over the past month, and this was pre-COVID.  It would be easy to become numb to data such as this and view it as simply another sad statement about the health of the US population, but perhaps instead we could see this as an opportunity. Certainly at the least we can engage our patients in a dialogue and use our stages of change assessment and motivational interviewing skills to determine how we might get them moving, even a little.  The “5 A’s” John describes above, though not studied for this purpose, provide a nice framework to consider, starting with the first 2!  It’s the least we could do to help try and turn the tide.  And check out the 2^nd Reference below for more resources for the CDC “Move Your Way” program.

References:

·         CDC.  Adult Physical Inactivity Prevalence Maps by Race/Ethnicity.  Published online January 2022.  Link

·         CDC:  “Move Your Way” program and Physical Activity Resources: Move Your Way

From PeerRxMed ( www.PeerRxMed.org )

3)  Give Me a Break!  The Practice of Self-Compassion

“If your compassion does not include yourself, it is incomplete.”  Jack Kornfield

“You’re such a bad ____!”   That inner critic doesn’t visit me often anymore, but when it does, it piles on quickly … “physician, teacher, leader, writer, husband, father, friend, son” are a few of the “usual suspects” that show up when it rears its ugly head, with “citizen of the world” thrown in this time for good measure.  It tried to move on to “You have such a bad ____”, but I declared “enough!”  As a perpetual optimist, when that voice shows up, I know it’s time to step back and check “under the hood” because something is not right.  Such was the case for me recently. 

It didn’t take me long to determine what the issue was – a combination of deadlines, my often ridiculously high self-expectations, feeling disconnected from myself and those close to me, and the heaviness of all going on in the world was overwhelming my emotional circuits.  In other words, I was feeling quite human.

Studies have shown that although physicians in general have higher levels of personal resilience than others, our tendency to be intolerant of our imperfections can contribute to many forms of personal and professional distress.  While trying to talk us out of our deeply rooted high standards will not likely succeed, there are methods to lessen the impact of these thoughts on our psyche by reprogramming the ways in which we view ourselves. This is the practice of self-compassion. 

According to Kristin Neff, PhD, self-compassion involves acting the same way towards yourself when you are having a difficult time, fail, or notice something you don’t like about yourself as you would with someone you loved dearly under the same circumstances.  When one is being self-compassionate, they are practicing the principle that you can’t give to others what you don’t have to give, so that the patience, kindness, and nonjudgement you show to yourself will ultimately be what you will bring to the world. 

The definitive action I took after noticing I had entered that self-berating vortex was pivotal, and not only saved me ongoing suffering, but also revealed that I am actually making progress (growth!) with the evolution of my emotional-management system.  Instead of entering my “default mode” of isolating myself with my thoughts and emotions, I acknowledged my struggles to myself (“you’re feeling overwhelmed”), reminded myself they were temporary (“this will pass”), and reached out and shared my struggles with those close to me (including my PeerRxMed partners).  All I need to say was, “I’m having a rough day emotionally” to both myself and to them, and they were there to listen.  Those conversations also opened the door for them to share some things they were struggling with, which likely would not have happened had I not shared my own.

So next time you notice you are “bad-thoughting” yourself (it will happen, with your own personal variation and preferred targets), give yourself a break and treat yourself like a person who is deserving of love and grace and patience … because you are.  And then do us all a favor, and pass it on. 

Further Resources: 

If you would like to create a life of greater self-compassion, here is a link to some self-compassion guided exercises and practices from Dr. Neff:  Self-Compassion Resources 

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org