Lesson 13, Volume 15—Strategies for Smoking Cessation

By Megan E. Piper, MA; Brion J. Fox, JD; and Michael C. Fiore, MD, MPH

Disclosure: The following work is derived from two works: (1) Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, June 2000. (2) Fiore MC, Bailey WC, Cohen SJ, et al. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service Report. JAMA 2000; 283(24):3244-3254.

Objectives

1. Review the impact of tobacco dependence and present tobacco dependence as a chronic disease.
2. Present treatment for patients willing to quit.
3. Discuss how to provide relapse prevention interventions.
4. Present treatment for patients who are not willing to quit.
5. Discuss how to treat special populations of tobacco users.

Key words

relapse prevention; smoking cessation; tobacco dependence

Abbreviations

FDA = Food and Drug Administration; PHS = Public Health Service

Tobacco is the single greatest cause of disease and premature death in the United States, responsible for more than 430,000 deaths each year. Approximately 25% of adult Americans currently smoke, and 3,000 children and adolescents become regular users of tobacco every day. Two important factors counter these discouraging statistics: 70% of all current smokers want to stop smoking and more than 7 out of 10 smokers visit a physician each year. In addition, we know that there are effective ways for physicians to treat tobacco use and dependence. Therefore, tobacco use and dependence represents an opportunity for physicians to intervene in an epidemic that has brought death and disability to millions of Americans.

The challenge is two-fold: first, convincing physicians of the critical importance of providing tobacco dependence treatment; and second, providing physicians the tools to effectively deliver these treatments. This paper is intended to help physicians overcome the second challenge by presenting the smoking cessation strategies from the evidence-based Clinical Practice Guideline Treating Tobacco Use and Dependence published by the US Public Health Service (PHS).¹

Tobacco as a Chronic Disease

One of the main themes within the PHS Guideline, Treating Tobacco Use and Dependence,¹ is that tobacco use results in true drug dependence, comparable to dependence on opiates, amphetamines, and cocaine. All of these drug addictions warrant clinical intervention, including tobacco dependence. Tobacco dependence shows many features of a chronic disease. While some tobacco users achieve permanent abstinence in an initial quit attempt, the majority typically cycle through multiple periods of relapse and remission and persist in tobacco use for many years. A failure to appreciate the chronic nature of tobacco dependence may undercut physicians' motivation to treat tobacco use consistently. By recognizing tobacco dependence as a chronic condition, physicians will better understand the relapsing nature of the ailment and the requirement for ongoing, rather than just acute, care. Additionally, this framework helps physicians view relapse as a subsequent component of this chronic disease, rather than as a personal failure, or a failure of their patients.

Treating Tobacco Use and Dependence

The findings of the PHS Guideline¹ emphasize the importance of treating all patients who use tobacco. In their analyses, the authors found that many different treatments can promote long-term abstinence. The first step in providing these efficacious treatments for tobacco use and dependence is identifying the problem by determining tobacco use status. According to the PHS Guideline,¹ asking whether or not a patient smokes not only increases the rates of physician intervention, but it also increases abstinence rates compared to controls who were not asked about their smoking status. Therefore, physicians and/or clinics should systematically identify all tobacco users at every visit. This can be done most efficiently with an office-wide system, such as including tobacco use status as one of the vital signs, adding a tobacco-use sticker to patient charts, indicating tobacco-use status on electronic medical records, or using a computer reminder system. The PHS Report² provides an algorithm for identifying and assessing tobacco use status (Fig 1). Once tobacco use has been documented and the physician has determined whether or not the patient is willing to quit smoking, the physician will be able to decide whether to use strategies to treat the patient willing to quit ("the five A's"), strategies to treat the patient unwilling to quit at this time ("the five R's"), or a relapse prevention intervention for a former smoker.

Figure 1. Algorithm for treating tobacco use.

Guideline Strategies: Treating Tobacco Users Willing To Quit

Every physician should begin with the five A's—ask, advise, assess, assist, and arrange.

Ask: It is imperative that physicians ask about tobacco use status at every visit. This occurs most consistently when there are systems in place, such as a vital sign stamp or electronic prompt on electronic medical records (Fig 2).

Figure 2. Vital signs stamp.

Advise: Once tobacco use status has been identified, physicians should advise all tobacco users to quit. Even brief advice to quit by a physician results in greater smoking abstinence rates. Indeed, smokers cite a physician's advice to quit as an important motivator for attempting to stop smoking. Therefore, physicians should strongly urge all tobacco users to quit. This advice should be clear (eg, "I think it is important for you to quit smoking now, and I can help you." "Cutting down while you are ill is not enough."). It should also be strong (eg, "As your physician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future."). And finally, the advice needs to be personalized to the patient's individual situation. Tie tobacco use to current health/illness, social or economic costs, motivation level or readiness to quit, or the impact of tobacco use on children or others in the household.

Assess: After providing a clear, strong, and personalized message to quit smoking, the physician must determine whether or not the patient is willing to quit at this time. If the patient is willing to make a quit attempt at this time, the physician can either assist the patient using a brief or intensive intervention or can refer the patient to an intensive intervention if the patient is willing. If the patient is not willing to make a quit attempt at this time, the physician should provide motivational interventions (see the five R's below).

Assist: Aiding the patient in his or her quit attempt can be done using either a brief or an intensive intervention. Level of intensity of the intervention has a strong dose-response effect. The longer the session of person-to-person contact and the more overall person-to-person contact, the more successful the treatment outcome. Person-to-person treatment delivered for four or more sessions also appears especially effective in increasing abstinence rates. Therefore, it is recommended that intensive interventions be used whenever possible. See Table 1 for the components of an intensive smoking cessation intervention. However, it is also important to note that even a minimal intervention, lasting < 3 min, can significantly increase overall tobacco abstinence rates.

How can the physician assist a tobacco user in quitting? First, help the patient develop a quit plan. In preparation for quitting, the patient should set a quit date, ideally within 2 weeks. The patient should tell his or her family, friends, and coworkers about the quit attempt and request understanding and support. It is important for the patient to anticipate challenges to the planned quit attempt, particularly during the critical first few weeks (eg, withdrawal symptoms such as negative mood, urges to smoke, and difficulty concentrating). Finally, the patient should remove tobacco products from his or her environment and prior to quitting, avoid smoking in places where he or she spends a lot of time (eg, work, home, car).

Second, the physician should develop a treatment plan. Treatment for tobacco use and dependence should include both counseling and pharmacotherapeutic treatment. Analyses have shown that there are three different counseling and behavioral therapies that significantly improve smoking abstinence rates: (1) provision of practical counseling (problem-solving/skills training) such as helping the patient identify events, internal states, or activities that increase the risk of smoking or relapse, identifying and practicing coping or problem-solving skills, and providing basic information about smoking and successful quitting; (2) provision of intratreatment social support by encouraging the patient, communicating caring and concern, and encouraging the patient to talk about the quitting process; and (3) helping the patient obtain extratreatment social support by training the patient in support-solicitation skills, prompting support seeking, and arranging outside support (Table 2).

According to the PHS Guideline,¹ all smokers trying to quit should receive pharmacotherapy except in the presence of special circumstances. Special consideration should be given before using pharmacotherapy with selected populations: those with medical contraindiciations, those smoking < 10 cigarettes/d, pregnant/breastfeeding women, and adolescent smokers. The PHS Guideline¹ has identified five first-line pharmacotherapies for smoking cessation: bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and nicotine patch. See Table 3 for clinical use and dosing. These medications have all been approved by the US Food and Drug Administration (FDA) for smoking cessation and have been shown to significantly improve abstinence rates. Because of the lack of sufficient data to rank-order these five medications, choice of a specific first-line pharmacotherapy must be guided by factors such as physician familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (eg, history of depression, concerns about weight gain). There are also two second-line pharmacotherapies, clonidine and nortriptyline, that have been shown to improve abstinence rates but have not been approved by the FDA for a smoking cessation indication and have more extensive side-effect profiles. Finally, the PHS Guideline¹ states that pharmacotherapies can be used long-term under certain circumstances and that pharmacotherapies can be combined. For example, the FDA has approved the use of bupropion SR for a long-term maintenance indication. In addition, there is evidence that combining the nicotine patch with either nicotine gum or nicotine nasal spray increases long-term abstinence rates over those produced by a single form of nicotine replacement therapy.

Arrange: Arranging follow-up contact is the final step in treating tobacco use and dependence. The physician should schedule a follow-up contact soon after the quit date, preferably within the first week. This early follow-up is recommended because the majority of smokers trying to quit subsequently return to smoking within the first 2 weeks. A second follow-up contact is recommended within the first month after quitting. These contacts can occur in person or over the telephone. During the follow-up contact, the physician should congratulate any success the patient has had, identify problems that have already occurred and anticipate new challenges to abstinence, assess pharmacotherapy use and problems, and, if indicated, consider use of or referral to more intensive treatment.

If the patient has used tobacco, discuss the circumstances surrounding the lapse and attempt to elicit a recommitment to quitting. Remind the patient that a lapse should be viewed as a learning experience. It takes most smokers two or more attempts to successfully quit smoking. Each time the patient relapses, he or she learns more about what will help and what will be harmful for the next quit attempt. Also, relapse is consistent with the chronic nature of tobacco dependence, it is not a sign of personal failure of the tobacco user or the physician.

Treating The Former Tobacco Use: Preventing Relapse to Tobacco Use

Because of the chronic relapsing nature of tobacco dependence, physicians should provide brief, effective relapse prevention treatment to all patients who have recently quit tobacco use. With the extraordinarily high rates of relapse to smoking, physicians must assist their patients in staying abstinent. Specifically, physicians should reinforce the patient's decision to quit, review the benefits of quitting, and assist the patient in resolving any residual problems arising from quitting. Minimal relapse prevention consists of congratulating success, encouraging continued abstinence, and discussing with the patient the benefits of quitting, the problems encountered during quitting, and the anticipated challenges to staying abstinent (eg, depression, weight gain, stress, alcohol, and other tobacco users in the household).

A more intensive prescriptive relapse prevention intervention, individualized to address the problems and concerns of the individual patient, can also be used by physicians. Some patients report feeling a lack of support for their cessation attempt. In response to this concern, the physician can schedule follow-up visits or telephone calls, help the patient identify sources of support within his or her environment, and work to increase his or her extratreatment social support or refer to the patient to an appropriate organization that offers smoking cessation counseling or support. If the patient reports negative mood or depression, the physician should provide counseling and, if appropriate, prescribe medication or refer the patient to a specialist. If the patient reports extended or severe withdrawal symptoms such as cravings, the physician should consider extending the use of approved pharmacotherapy or combining pharmacotherapies to reduce the nicotine withdrawal.

Weight gain is a common concern among smokers who are trying to quit. It is important that the physician be honest and inform the patient that some weight gain is quite common but it is usually self-limiting. Emphasize the importance of a healthy diet and physical activity, but discourage strict dieting. The physician may also choose to maintain the patient on pharmacotherapy known to delay weight gain (eg, bupropion SR or nicotine replacement therapies, particularly nicotine gum). If patients report flagging motivation and feelings of deprivation, the physician should reassure the patient that these feelings are common, recommend rewarding activities, and continue to emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

Although most relapse occurs early in the quitting process, some relapse occurs months or even years after the quit date. Therefore, physicians should continue to engage in relapse prevention interventions even with former tobacco users who no longer consider themselves actively engaged in the quitting process.

Guideline Strategies: Treating Patients Who Are Unwilling to Quit

If a physician has identified a tobacco user and advised the patient to quit, but he or she reports being unwilling to make a quit attempt at this time, it is important for the physician to attempt to motivate the patient to quit. The PHS Guideline¹ suggests using a strategy based upon the 5 R's: relevance, risks, rewards, roadblocks, and repetition.

Relevance: Physicians should encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (eg, having children in the home), health concerns, age, sex, and other important patient characteristics (eg, prior quitting experience, personal barriers to cessation).

Risks: Physicians should ask the patient to identify potential negative consequences of tobacco use. Acute risks include shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, and increased serum carbon monoxide. Long-term risks include heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), COPD (chronic bronchitis and emphysema), long-term disability, and need for extended care. Environmental risks include increased risk of lung cancer and heart disease in spouses; higher rates of smoking by children of tobacco users; increased risk for low birth weight, sudden infant death syndrome, asthma, middle ear disease, and respiratory infections in children of smokers. Physicians may suggest and highlight those that seem most relevant to the patient.

Physicians should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (eg, smokeless tobacco, cigars, and pipes) will not eliminate these risks.

Rewards: Physicians should ask the patient to identify potential benefits of stopping tobacco use. Physicians may suggest and highlight those that seem most relevant to the patient (eg, improved health; improved sense of smell; food will taste better; saving money; improved self-esteem; home, car, clothing, and breath will smell better; no more worrying about quitting; setting a good example for kids; have healthier babies and children; no more worrying about exposing others to smoke; feel better physically; perform better in physical activities; and reduced wrinkling/aging of skin).

Roadblocks: Physicians should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem-solving, pharmacotherapy) that could address barriers. Typical barriers might include withdrawal symptoms, fear of failure, weight gain, lack of support, depression, and enjoyment of tobacco.

Repetition: Motivational interventions should be repeated every time an unmotivated patient visits the clinic setting.

Treating Tobacco Use and Dependence in Special Populations

The PHS guidelines for treating tobacco use and dependence address numerous special populations, including women, pregnant women, racial and ethnic minorities, hospitalized smokers, smokers with other psychiatric comorbidities and/or chemical dependency, children and adolescents, and older smokers. Generally, the same treatments are found to be effective in all populations.

Women

Smoking cessation clinical trials reveal that the same treatments benefit both men and women. Therefore, the same interventions can be used for both men and women. However, research suggests that some treatments are less efficacious in women than in men (eg, nicotine replacement therapies). Additionally, although research suggests that women benefit from the same interventions as do men, women may face different stressors and barriers to quitting that may be addressed in treatment. These include greater likelihood of depression, greater weight control concerns, hormonal cycles, and others. This suggests that women may benefit from tobacco dependence treatments that address these topics. Finally, women who are considering becoming pregnant may be especially receptive to tobacco dependence treatment.

Pregnant Women

Because smoking in pregnancy imparts risks to both the woman and the fetus, many women are motivated to quit during pregnancy, and health-care professionals can take advantage of this motivation by reinforcing the knowledge that cessation will reduce health risks to the fetus and that there are postpartum benefits for both the mother and child. Quitting smoking prior to conception or early in the pregnancy is most beneficial, but health benefits result from abstinence at any time. Therefore, a pregnant smoker should receive encouragement and assistance in quitting throughout her pregnancy. The PHS Guideline¹ recommends that whenever possible, pregnant smokers should be offered extended or augmented psychosocial interventions that exceed minimal advice to quit.

Racial and Ethnic Minorities

Tobacco dependence and desire to quit appear to exist in all racial and ethnic groups. Moreover, ethnic and racial minority groups in the United States—African-Americans, American Indians/Native Americans, Alaskan Natives, Asian and Pacific Islanders, Hispanics—experience high mortality in a number of smoking-related disease categories. Therefore, there is a critical need to deliver effective tobacco dependence interventions to ethnic and racial minorities.

Studies have demonstrated the efficacy of a variety of smoking cessation interventions in minority populations. The nicotine patch, physician advice, counseling, and tailored self-help manuals, tailored self-help materials, and telephone counseling have been shown to be effective with African-Americans. Nicotine patch and self-help materials including a mood management component have been shown to be effective with Hispanic smokers. Screening for tobacco use, physician advice, clinic staff reinforcement and follow-up materials have been shown to be effective for Native American populations. As a result, the Panel recommends that members of racial and ethnic minority groups be provided treatments that have been shown to be effective in the Guideline.¹

Few studies have examined interventions specifically designed for particular ethnic or racial groups, and there is no consistent evidence that targeted cessation programs result in higher quit rates in these groups than do generic interventions of comparable intensity. Therefore, physicians should offer treatments identified as effective to all of their patients. It is essential, however, that cessation counseling or self-help materials be conveyed in a language understood by the smoker. Additionally, culturally appropriate models or examples may increase the smoker's acceptance of treatment. Physicians should remain sensitive to individual differences and health beliefs that may affect treatment acceptance and success in all populations.

Hospitalized Smokers

It is vital that hospitalized patients attempt to quit smoking, because smoking may interfere with their recovery by negatively affecting bone and wound healing. Among cardiac patients, second heart attacks are more common in those who continue to smoke. Patients who are treated successfully for cancer of the lung or head and neck, but who continue to smoke, are at elevated risk for a second cancer.

The PHS Guideline¹ revealed that providing hospitalized smokers with an augmented intervention significantly increases abstinence rates compared with usual care. Therefore, hospitalized smokers should be given augmented interventions. Patients in long-term care facilities should also receive tobacco dependence interventions identified as efficacious in the PHS Guideline.¹

Smokers With Psychiatric Comorbidity and/or Chemical Dependency

According to the PHS Guideline,¹ smokers with comorbid psychiatric conditions should be provided smoking cessation treatments found to be effective in the general population of smokers. While psychiatric comorbidity places smokers at increased risk for relapse, such smokers can be helped by smoking cessation treatments. Currently there is insufficient evidence to determine whether smokers with psychiatric comorbidity benefit more from specialized or tailored cessation treatments than from standard treatments. Because bupropion SR and nortriptyline are effective at treating depression and are efficacious smoking cessation medications, they should especially be considered for use in depressed patients.

Some smokers may experience exacerbation of a comorbid condition upon quitting smoking, but most evidence suggests that abstinence entails little adverse impact (eg, little increase in aggression). It is important to note that stopping smoking may affect the pharmacokinetics of certain psychiatric medications. Therefore, physicians may wish to monitor closely the actions or side effects of psychiatric medications in smokers making a quit attempt.

The treatment of tobacco dependence can be provided concurrent with treatment for other chemical dependencies (alcohol and other drugs). With regard to patients in treatment for chemical dependency, there is little evidence that patients with other chemical dependencies relapse to other drug use when they stop smoking. However, such patients should be followed closely after they stop smoking.

Children and Adolescents

The PHS Guideline¹ recommends that physicians screen pediatric and adolescent patients and their parents for tobacco use and provide a strong message about totally abstaining from tobacco use. A recent study has shown that adolescents' smoking status was identified in 72% of office visits, but smoking cessation counseling was provided at only 17% of clinic visits of adolescent smokers. Therefore, physicians need both to assess adolescent tobacco use and to offer cessation counseling and behavioral interventions shown to be effective with adults. It is also recommended that the content of these interventions be modified to be developmentally appropriate. Children and adolescents may benefit from community- and school-based intervention activities. The messages delivered by these programs should be reinforced by the physician. The Guideline¹ further recommends that clinicians in a pediatric setting offer stop-smoking advice to parents to limit children's exposure to second-hand smoke.

Older Smokers

It is estimated that 13 million Americans aged ÿ 50 years and 4.5 million adults > 65 years smoke cigarettes. Smokers > 65 years can both quit smoking and benefit from abstinence. Smoking cessation in older smokers can reduce the risk of myocardial infarction, death from coronary heart disease, and lung cancer. Moreover, abstinence can promote more rapid recovery from illnesses that are exacerbated by smoking and can improve cerebral circulation. Age does not appear to diminish the benefits of quitting smoking.

The smoking cessation interventions that have been shown to be effective in the general population have also been shown to be effective with older smokers, and the PHS Guideline¹ recommends that they be used to treat older adults. Research has demonstrated the efficacy of guideline-based treatments, including counseling interventions, physician advice, buddy support programs, age-tailored self-help materials, telephone counseling, and the nicotine replacement therapies in treating tobacco use and dependence in adults aged ÿ 50 years.

Conclusion

Tobacco presents a serious health risk to all smokers. Luckily, many smokers want to quit and the PHS Guideline¹ recommendations provide physicians with the tools with which to help them. The Guideline¹ establishes efficacious strategies to assist smokers who want to quit (the "five A's"), strategies for smokers who are not willing to quit at this time (the "five R's"), and relapse prevention strategies that physicians can use to treat current and former smokers. These strategies can and should be used with all smokers. Even a brief, 3-min intervention by a physician has been shown to have an impact on helping smokers quit and stay abstinent. Smoking cessation is an important goal for all smokers, and physicians can facilitate this difficult task.

References

1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service, June 2000
2. Fiore MC, Bailey WC, Cohen SJ, et al. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service Report. JAMA 2000; 283(24):3244-3254

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