TOBACCO SMOKING CESSATION AND OBESITY
Educational Objectives
| The goal of this program is to improve management of smoking cessation and weight loss. After hearing and assimilating
this program, the clinician will be better able to:
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 | Assess patients’ readiness for lifestyle changes.
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| Use motivational interviewing strategies to help patients take action to quit smoking.
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| Compare the pharmacotherapeutic agents approved by the Food and Drug Administration for smoking cessation.
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| Advise patients about lifestyle interventions for weight loss and maintenance.
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| Identify patients who may benefit from bariatric surgery and counsel them appropriately.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgments
Dr. Mallin was recorded at An Intensive Review of Family Medicine, presented by Medical University of South Carolina,
Department of Family Medicine, and held June 9-14, 2008, on Kiawah Island, SC; Dr. Kanaya was recorded at
Obstetrics and Gynecology Update: What Does the Evidence Tell Us?, presented by the University of California, San
Francisco, School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, and held October
17-19, 2007, in San Francisco, CA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation
in the production of this program.
| TOBACCO SMOKING CESSATION—Robert Mallin, MD, Associate Professor, Departments of Family Medicine, and
Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
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| Epidemiology: 440,000 deaths attributed to smoking each year in United States; annual health care costs associated with
smoking, ≈$167 billion; South Carolina statistics—22.3% of adults and 19.1% of high school students smoke (dramatic
decrease in latter figure in past 2 yr, likely due to culture shift); ≈15% of pregnant women smoke during third trimester;
≈57% of adults have tried to quit at least once during past 12 mo, and 70% report wanting to quit; mortality
rates—50% of smokers die of smoking-related complications; quitting smoking at 30 yr of age increases average
lifespan by 10 yr; benefit decreases with increasing age at smoking cessation, but quitting at 60 yr of age still adds 3 to 4
yr to average lifespan
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| Primary care interventions: 5 A’s of smoking cessation—ask patient about tobacco use; advise patient to quit; assess
willingness to quit; assist those willing to quit; arrange for follow-up; tips—add tobacco use to medical chart (as vital
sign) and check at every visit (greatly increases likelihood of counseling patient about smoking); advise every patient to quit;
be clear, direct and unequivocal; personalize discussion, eg, by relating potential consequences to patient’s experience and
plans for future
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| Stages of change: reflect degree of patient’s willingness to quit; precontemplation—not interested in quitting smoking
(≈30% of smokers); contemplation—interested but not ready to quit; preparation—taking steps toward quitting (eg,
setting quit date); action—begins first day of smoking cessation; requires maintenance, or relapse will occur
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| Stage-specific strategies: precontemplation—education; persistent advice; contemplation—ask patient what he or she
likes about smoking (pros); debunk stated pros (eg, if patient cites improved concentration, explain that loss of concentration
early sign of nicotine withdrawal; withdrawal begins within 2 hr of nicotine dose); emphasize cons; discuss
smoking cessation at every visit
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| Motivational interviewing: approach to discussing smoking cessation; relevance—patient identifies personal relevance
of smoking cessation; emotional context important, because addiction involves mesolimbic system, not cortex (insufficient
to appeal to intellectual reasoning); establishing personal relevance provides motivation during periods of craving;
risks—educate patient, emphasizing smoking-related risks; rewards—educate patient about benefits of smoking cessation;
encourage patient to have related reward (eg, using money saved by quitting smoking for vacation fund);
roadblocks—identify potential barriers to quitting (eg, weight gain, depression); repetition—follow up at each visit
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| Preventing relapse: help patients identify smoking triggers (what makes them want to smoke) and coping strategies;
basic information—any smoking likely to result in relapse; withdrawal symptoms peak between 1 and 3 wk of smoking
cessation; average craving lasts 2 min; withdrawal symptoms include depressed mood, irritability, cravings, and difficulty
concentrating; support—communicate caring and concern when encouraging patient to quit smoking; encourage
patient to talk about process of quitting; provide supportive materials (eg, videos); have patient enlist outside support (eg,
friends and family members); set quit date; discuss pharmacotherapy
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| Pharmacotherapy: bupropion—dosed 150 mg once daily, then bid; contraindicated in patients with seizure or eating
disorders; typically taken for 7 to 12 wk (up to 6 mo); costs $3.30 per day (less than cost of pack of cigarettes in most
states); nicotine replacement therapy—gum available over-the-counter (OTC), but (like all nicotine replacement
strategies) ineffective without comprehensive smoking cessation program; inhaler device mimics action of smoking,
but expensive and may cause irritation; nasal spray often causes nasal irritation; transdermal system (patch) available
in 3 doses (21, 14, and 7 mg); second-line medications—clonidine and nortriptyline have modest effects
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| Choosing dose of nicotine patch: points attributed based on answers to 3 questions; 1) number of cigarettes smoked daily;
2) timing of smoking upon awakening; 3) duration patient can comfortably go without smoking; dose—7-mg patch
for patients with score of 1 to 2 points; 14-mg patch for those scoring 3 to 4 points; 21-mg patch for those scoring \>4
points; very heavy smokers may require additional nicotine therapy (eg, gum)
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| Varenicline: partial agonist of ⓮ ⓶ subtypes of nicotinic acetylcholine receptor; competes with nicotine for receptors;
efficacy—clinical trials show greater efficacy with varenicline than than with bupropion and nicotine replacement strategies;
speaker estimates success rates >50% in his practice; adverse effects—nausea most common; Food and Drug
Administration (FDA) has issued alert of potential association with psychiatric adverse effects (eg, suicidal ideation)
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| Abbreviated method for intervention: ask whether patient smokes or uses tobacco product; advise patient to quit;
refer patient to quit line (free support service for patients who want to quit or have already quit) or local service
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| Questions and answers: when couples smoke—best if both partners quit at same time (otherwise, high rates of relapse);
speaker helps patient quit, even if partner continues to smoke; creating cognitive dissonance—useful technique
when counseling patients in contemplative phase; clinician points out inconsistencies in patient’s actions or between
stated goals and actions; resulting cognitive dissonance may propel patient toward smoking cessation
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| MANAGEMENT OF OBESITY IN WOMEN—Alka M. Kanaya, MD, Assistant Professor, Departments of Medicine and
Epidemiology and Biostatistics, University of California, San Francisco, School of Medicine
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| Definitions: obesity—increase in fat accumulation that adversely affects health; body mass index (BMI)—
underweight, BMI <18.5; healthy weight, 18.5 to 25; overweight, 25 to 29.9; obese ≥30; category delineations hold for
most ethnicities (cutoffs lower for Asians)
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| Epidemiology: in 2007, ≈31% of adults in United States met criteria for obesity; projections estimate rate of ≈45% by
year 2025; similar trends seen in other countries; in United States, prevalence has significantly increased over last decade
and has affected both sexes and all ethnic groups; among blacks and Mexican-Americans, women have higher rates of
obesity than men; among whites, rates of obesity similar for men and women; suggested contributors to trend in
obesity—busy lifestyle leads to many meals eaten away from home; high intake of energy-dense foods; misconceptions
about low-fat foods (low-fat foods do not typically have significantly reduced calories); “portion distortion” (portion
sizes served at restaurants have increased over last decade); other contributing factors also likely; long-term follow-up
from Framingham cohort showed that social circle highly influences tendency toward overweight or thinness
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Diet
| Dietary composition: typical American diet consists of 50% carbohydrates, 20% protein, and 30% fat; United States
Department of Agriculture (USDA) food pyramid and Weight Watchers diets similar, with 55% to 60% carbohydrates,
10% to 15% protein, and <30% fat; Zone and South Beach diets considered moderate, with slightly reduced carbohydrates
and increased protein; extreme diets include Atkins (very low carbohydrate) and Ornish (high carbohydrate; very
low fat)
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| Comparisons of popular diets: direct comparisons of Atkins, Ornish, Weight Watchers, and Zone diets found similar
amounts of weight loss (average, 3 kg) at 1 yr among otherwise healthy obese patients; self-reported rates of adherence
influenced outcomes (increased weight loss with increasing adherence); no long-term studies on dietary interventions;
similar trial conducted in England also found no significant differences in outcomes at 6 mo; most weight loss occurred
early, and many patients regained weight by end of study
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| Conclusions: adherence more important than choice of diet; weight loss result of energy output exceeding energy input;
ideal macronutrient composition remains unknown; no data on long-term safety of very low-carbohydrate diets (potential
adverse effects on kidneys, bones, and heart); moderate-fat diets promote sustainable weight loss and favorable lipid profile;
strict low-fat diets associated with cardiovascular benefit (eg, angiographic evidence of regression of coronary artery
disease); maintenance of weight loss—combination of diet and exercise improves success; 50% of individuals lose
weight without participating in formal program; dietary composition of 55% carbohydrates, 20% protein, and 25% fat
seems to support maintenance of weight loss; extreme diets associated with low compliance over long term
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| Tips for patients: assess readiness for lifestyle change; set realistic expectations (first 5% of weight loss most important
for health outcomes, eg, blood pressure [BP], lipid profiles, glucose metabolism); control portion size; incorporate fresh
fruits and vegetables into diet; after losing weight, focus on maintenance
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Exercise
| Fitness: study showed that in nonobese unfit (based on aerobic fitness tests) individuals, risks for adverse events similar to
or greater than risk in obese aerobically fit individuals
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| Exercise and weight loss: when combined with dietary changes, exercise results in additional benefit; most trials last
<6 mo and follow surrogate end points (eg, changes in lipid profiles and BP) rather than long-term outcomes; duration
and intensity of exercise—trial looked at moderate and vigorous intensity and duration among cohort of sedentary
obese women (average BMI, 34; average age, ≈35 yr); at 1 yr, no significant differences among 4 groups (weight loss
≈10%); post hoc analysis of data showed benefit of longer duration, but not of higher intensity; participants exercising
≥200 min/wk had most weight loss
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| Guidelines: prevention of heart disease—≥30 min of moderate intensity exercise (eg, brisk walking) daily for ≥5 days;
weight loss— ≥60 min of moderate intensity exercise on most days; begin with ≥150 min/week, then increase to ≥60
min/day
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Pharmacotherapy
| Adverse effects: older drugs (many no longer used) associated with severe complications (eg, hypertension, tachycardia,
death); ephedra banned from sale and phenylpropanolamine taken off market; thyroid hormone (used during 1960s and
1970s) associated with many adverse effects
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| Approved medications: phentermine—suppresses appetite; associated with cardiovascular adverse effects;
sibutramine—suppresses appetite; enhances energy expenditure; associated with hypertension; orlistat—available
OTC; inhibits absorption of fat; may cause diarrhea
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| Efficacy: comparable effects; patients lose 3 to 4 kg, on average, but wide variation occurs; weight loss occurs during
first 6 mo, after which weight stabilizes (then often increases somewhat); weight regain common after discontinuing
medication
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| Importance of lifestyle modifications: lifestyle changes alone result in slightly better weight loss than pharmacotherapy
alone; combination of lifestyle modifications and pharmacotherapy results in greatest weight loss
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| Rimonabant: agent not approved in United States, but used in 30 countries, including Canada; cannabinoid receptor antagonist;
adverse effects include depression; studies show improvements in weight, waist circumference, triglycerides,
and high-density lipoprotein cholesterol (all plateau with time); data on long-term safety needed
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| Principles of pharmacotherapy: National Institutes of Health (NIH) reserves use for obese patients or very overweight
patients with comorbidity who are motivated to begin structured lifestyle interventions; ≥1 mo of successful adherence
to diet and exercise plan recommended before initiating pharmacotherapy; drug targets—many potential
targets for weight loss; future approaches may mirror those used for BP control (ie, adding different medications with different
targets to achieve control)
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Bariatric Surgery
| Options: gastric bypass—most popular approach in United States; creates small gastric pouch and separates it from rest of
fundus; reattaches portion of duodenum to stomach, creating blind loop; adjustable gastric banding—silicone band placed
around top of stomach (may be adjusted to increase degree of restriction)
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| Efficacy: significant weight loss and improvement in comorbidities; meta-analysis shows high rates of resolution of diabetes,
hyperlipidemia, hypertension, and sleep apnea; long-term outcomes—Swedish study with 15-yr follow-up showed best results
(≈25% reduction in weight) associated with gastric bypass surgery; gastric banding and gastroplasty also associated with
long-term weight loss; another Swedish study showed mortality benefit; 24% risk reduction at 16 yr; benefit evident after 6 yr
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| Safety: perioperative mortality—1%; morbidity 30% to 50%; reoperations and hospitalizations common;
reimbursement—approved by most payors; follow-up—patients require lifelong surveillance for complications (eg, vitamin
deficiencies)
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| Candidates: patients with BMI ≥40, or ≥35 with comorbidities, and only after failure of less invasive methods of weight
loss; other qualifications—realistic expectations; good social support; no active substance abuse or history of unstable
psychiatric condition; adherence to medical recommendations; prerequisites for surgery—bariatric surgery program at
University of California, San Francisco, requires 10% weight loss before surgery; multidisciplinary evaluation includes
imaging, laboratory tests, and psychiatric evaluation
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| Take-home points: set realistic goals for weight loss (applies to all strategies); control portion size; choose diet most
compatible with lifestyle; exercise ≥60 min/day on most days; focus on fitness at any weight
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| Questions and answers: importance of dedicated exercise—regular daily activities typically insufficient; wearing
pedometer useful to increase awareness; 7000 to 10,000 steps/day recommended for weight loss (requires dedicated effort);
several short bouts of exercise (30-60 min cumulatively) acceptable; all-liquid diets—very low-calorie (≤100
kcal/day) diets using shakes as meal replacements sometimes used short-term for bariatric surgery candidates under supervision
of health care professional; patients generally regain weight once regular diet resumed; “yo-yo” dieting has
negative impact on health; dieting and muscle mass—diet restriction alone results in equal loss of fat and lean mass;
exercise and adequate protein intake important for maintaining muscle mass; studies in older adults show increased lean
mass (regardless of fat mass) associated with longer lifespan
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Suggested Reading
Buchwald H et al: Bariatric surgery: a systematic review and meta-analysis. JAMA 292:1724, 2004; Covey LS et al:
Smokers’ response to combination bupropion, nicotine patch, and counseling treatment by race/ethnicity. Ethn Dis 18:59,
2008; Dansinger ML et al: Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and
heart disease risk reduction: a randomized trial. JAMA 293:43, 2005; Erol S, Erdogan S: Application of a stage based
motivational interviewing approach to adolescent smoking cessation: the Transtheoretical Model-based study. Patient
Educ Couns 72:42, 2008; Hays JT et al: Efficacy and safety of varenicline for smoking cessation. Am J Med 121(4
Suppl 1):S32, 2008; Jakicic JM et al: Effect of exercise duration and intensity on weight loss in overweight, sedentary
women: a randomized trial. JAMA 290:1323, 2003; Kaly P et al: Unrealistic weight loss expectations in candidates for
bariatric surgery. Surg Obes Rel Dis 4:6, 2008; Lutes LD et al: Small changes in nutrition and physical activity promote
weight loss and maintenance: 3-month evidence from the ASPIRE randomized trial. Ann Behav Med Jun 21, 2008 [Epub
ahead of print]; Moorman M, van den Putte B: The influence of message framing, intention to quit smoking, and
nicotine dependence on the persuasiveness of smoking cessation messages. Addict Behav May 24, 2008 [Epub ahead of
print]; Nides M: Update on pharmacologic options for smoking cessation treatment. Am J Med 121(4 Suppl 1):S20,
2008; Prochaska JJ et al: Physical activity as a strategy for maintaining tobacco abstinence: a randomized trial. Prev
Med May 16, 2008 [Epub ahead of print]; Robles GI et al: A review of the efficacy of smoking-cessation pharmacotherapies
in nonwhite populations. Clin Ther 30:800, 2008; Smith DW et al: Confirming the structure of the Why Do You
Smoke? questionnaire: a community resource for adolescent tobacco cessation. J Drug Educ 38:85, 2008; Toouli J et
al: Efficacy of a low-pressure laparoscopic adjustable gastric band for morbid obesity: patients at long term in a multidisciplinary
center. Surg Obes Relat Dis 4(3 Suppl):S31; Wexler R et al: Adoption of exercise and readiness to change differ
between whites and African-Americans with hypertension: a report from the Ohio State University Primary Care
Practice-Based Research Network. J Am Board Fam Med 21:358, 2008.
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