The role of clinicians in smoking cessation
The role of clinicians in smoking cessation
The number of effective treatments to deter tobacco use is larger than ever. We offer a brief summary of what the experts recommend.
Updated guidelines from the U.S. Public Health Service for treatment of tobacco dependence aim to change not only the habits of smokers but also the practice patterns of primary-care clinicians managing these patients. Every patient who uses tobacco should be identified, advised to quit, and offered scientifically sound treatments.
“It is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions,” point out the authors of the report, entitled Treating Tobacco Use and Dependence: 2008 Update.
The 37 panelists—representing the CDC, the National Cancer Institute, National Institute on Drug Abuse, and four other groups—sifted through 8,700 research articles, finding important progress since the last guidelines were published in 2000. The field of FDA-approved tobacco-use medications has grown to seven, and certain combinations of agents also have been shown to be effective. Even stronger evidence now points to counseling as an effective strategy.
It all starts with two questions
The guidelines recognize tobacco dependence as a chronic condition that often requires repeated interventions to attain long-term abstinence. To that end, clinicians are urged to pose two questions to every patient: “Do you smoke?” and “Do you want to quit?” If the patient wants to quit, the clinician should encourage the use of individual, group, and telephone counseling services and discuss appropriate medications to aid those efforts. For people unwilling to quit at that time, the guidelines suggest motivational treatments to plant the seeds for future attempts.
You can make a difference—and quickly too
The guidelines present specific strategies that take less than 10 minutes to be used by clinicians who see a wide variety of patients and are bound by time constraints. Clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts even when the person isn't currently willing to try to stop.
Follow “the five As”
The guidelines were accompanied by a revised handbook for clinicians, “Helping Smokers Quit." This spells out “the five As” that clinicians should implement for every patient:
1. Ask about tobacco use. Identify and document tobacco- use status for every patient at every visit.
2. Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.
3. Assess willingness to make a quit attempt. Is the tobacco user willing to make an attempt at this time?
4. Assist in quit attempt. Offer medication and provide or refer for counseling or additional treatment to help patients who want to quit. Help set a quit date, preferably one within two weeks. Advise would-be quitters to remove tobacco products from their environment and to enlist the support of family members, friends, and coworkers. Have them identify the benefits of quitting and the challenges they can expect to face. Remind them that total abstinence is essential, and that drinking alcohol is strongly associated with relapse. Allowing others to smoke in their home can also hinder their cessation efforts. For patients unwilling to quit yet, provide interventions designed to increase future attempts.
5. Arrange follow-up. Arrange for follow-up contacts, beginning within the first week after the quit date. For other tobacco users, address tobacco dependence and willingness to quit at the next clinic visit.
There are seven first-line medications (five nicotine-based and two non-nicotine) that have been shown to reliably increase long-term rates of smoking abstinence: nicotine gum, inhaler, lozenge, nasal spray, and patch; bupropion SR (Wellbutrin SR, Zyban SR); and varenicline (Chantix). Patients who use these agents must adhere closely to the recommended doses and durations.
Combination therapy. Among first-line medications, there is evidence of increased long-term (>14 weeks) abstinence rates with the following combinations: nicotine patch with nicotine gum or nicotine nasal spray, nicotine patch with the nicotine inhaler, nicotine patch with bupropion. However, combining varenicline with nicotine replacement therapy (NRT) agents has been associated with higher rates of nausea, headaches, and other side effects.
Long-term use. The use of these medications for up to six months does not present a known health risk, and developing dependence is uncommon. Additionally, the FDA has approved bupropion SR, varenicline, and some NRT medications for six-month use. Gender gaps in effectiveness. Some evidence suggests NRT is less effective in women than men, so the clinician may want to consider bupropion SR or varenicline for female patients.
Weight gain. Data show that using bupropion SR and NRT, in particular 4-mg nicotine gum and 4-mg nicotine lozenge, delay—but do not prevent—weight gain.
Light smokers. Although the 2008 guidelines offer the new recommendation that light smokers (<10 cigarettes/day) should be identified, strongly urged to quit, and provided cessation-counseling interventions, cessation medications have not been shown to be of benefit in this group.
Second-line agents. Consider prescribing second-line agents—clonidine (Catapres) and nortriptyline (Pamelor)—for patients unable to use first-line medications.
Motivating the reluctant quitter
Clinicians should bear in mind that the combination of counseling and medication is more effective than either approach taken alone. Therefore, whenever feasible and appropriate, both multiple counseling sessions and medication should be provided.
A new recommendation is that clinicians should use motivational techniques to encourage future cessation attempts among smokers not willing to stop. The motivational steps center on “the 5 Rs”:
• Relevance. Encourage the patient to indicate why quitting is personally relevant, being as specific as possible.
• Risks. Ask the patient to identify potential negative consequences of tobacco use; emphasize that smoking low-tar/low-nicotine cigarettes or using other forms of tobacco, such as chewing tobacco, cigars, and pipes, will not eliminate these risks.
• Rewards. Ask the patient to identify potential benefits of stopping tobacco use.
• Roadblocks. Ask the patient to identify barriers or impediments to quitting, and provide treatment (problem-solving counseling, and/or medication) that could address these barriers.
• Repetition. Repeat the motivational intervention at every visit. Tobacco users who have failed in previous quit attempts should be told that most people make repeated attempts before they succeed.
Work continues after cessation
Smokers who have recently quit face a high risk of relapse, usually early in the cessation process but sometimes months or even years later. The 2008 guidelines indicate that currently, the best strategy for achieving long-term abstinence appears, as in the case of the reluctant quitter, to be the use of medication and a few sessions of brief counseling—in this case, four or more 10-minute sessions. During counseling, reinforce the patient's success by reviewing the benefits of quitting and offer to help resolve any problems arising from quitting, such as depression, weight gain, or discouragement presented by other tobacco users in the household.
If patients complain about a lack of support for their continued cessation efforts, for example, you can keep them on track by scheduling follow-up visits or telephone calls, or by urging them to call a telephone quit line or contact an organization that offers counseling or support.
If former smokers report significant negative mood or depression, provide counseling, prescribe appropriate medication, or refer to a specialist. If patients report prolonged craving or other withdrawal symptoms, consider extending the use of an approved medication or adding/combining medications. If weight gain is the problem, reassure patients that some weight gain after quitting is common and usually self-limiting. Emphasize the importance of a healthy diet and active lifestyle, and recommend starting or increasing physical activity. Suggest low-calorie tobacco substitutes such as sugarless chewing gum, vegetables, or mints. Refer patients to a nutritional counselor or program.
If a patient has a relapse or feels it could occur, suggest continued use of medications. Also point out that quitting may require multiple attempts and the lapse should be viewed as a learning experience.