60Smoking Cessation

Publication Details

More than 400,000 people die of tobacco-related causes annually. Cigarette smoking is the leading cause of preventable death in the United States, and smoking cessation is a critically important topic for patient counseling because of its potential benefit. Figure 60.1 shows the benefits of smoking cessation for different parts of the smoker's body. Evidence also suggests that nonsmokers who are exposed to environmental tobacco smoke are susceptible to lung cancer and possibly coronary heart disease. Rates of chronic middle ear effusions, pneumonia, and asthma are increased among children who are exposed to environmental tobacco smoke.

Figure 60.1. Benefits of Smoking Cessation.

Figure

Figure 60.1. Benefits of Smoking Cessation. From: Centers for Disease Control, Office on Smoking and Health. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, At a Glance, 1990. Rockville, Md: Centers for (more...)

Primary care clinicians can play a key role in helping patients quit smoking. Even very simple interventions by clinicians can lead to long-term quit rates of 5% to 10%. More extensive interventions, including use of nicotine gum and patches, can lead to quit rates that are significantly higher. If all primary care providers used simple interventions such as asking about smoking status and suggesting that patients quit smoking, the national smoking cessation rate could double. Recent studies indicate, however, that fewer than half of patients who smoke receive any assistance in quitting from their health care providers.

See chapter 24 for information on counseling children and adolescents on prevention of tobacco use. See chapters 19 and 54 for information about counseling on dental and oral health for children and adolescents and for adults, respectively. See chapters 18 and 53 for information about counseling on alcohol and other drug abuse for children and adolescents and for adults, respectively.

Recommendations of Major Authorities

  • All major authorities, including the American Academy of Family Physicians (AAFP), American Cancer Society, American College of Obstetricians and Gynecologists, American College of Physicians, American Medical Association, Canadian Task Force on the Periodic Health Examination, National Heart, Lung, and Blood Institute, National Institute of Dental Research, and US Preventive Services Task Force, and the Smoking Cessation Guideline Panel convened by the Agency for Health Care Policy and Research and the Centers for Disease Control and Prevention --
  • For patients who smoke, clinicians should provide smoking cessation counseling, consider drug therapy with nicotine products, and referral as appropriate to smoking cessation programs. The AAFP recommends counseling be done on a regular basis to smokers, as multiple messages are often needed, and the harmful effect of smoking on children's health be emphasized to smoking parents.
  • Several major authorities, including Joint Commission on Accreditation of Health Care Organizations --
  • Smoking should be prohibited in health-care facilities.

Basics of Smoking Cessation Counseling 1

1.

Consider designating an office smoking cessation coordinator who will be responsible for the administration of the smoking cessation program.

2.

Systematically identify smokers:

  • Treat smoking status as a vital sign.
  • Place a sticker or other visual cue on the charts of patients who smoke as a reminder of the need to address the issue of smoking at every visit. (Similar stickers may be placed on the charts of children of smokers to serve as cues to talk to parents about the ways in which smoking endangers their children).
  • Use a flow chart in patient records to keep track of smoking cessation interventions.
  • Use of a brief, self-administered questionnaire (Table 60.1) may facilitate assessment of smoking status.

3.

Strongly advise all smokers to stop smoking:
Advice should be:

  • Clear: "I think it is important for you to quit smoking now and I will help you. Cutting down when you are ill is not enough."
  • Strong: "As your clinician I need you to know that quitting smoking is the most important thing you can do to protect your current and future health."
  • Personalized: Tie smoking to current health or illness; the social and economic costs of tobacco use; motivation level/readiness to quit; and /or the impact of smoking on children and others in the household.

4.

Ask every smoker if he/she is ready to make a quit attempt.

5.

Assist patients who are ready to quit:

  • Set a quit date: ideally, within 2 weeks
  • Counsel patients who are preparing to quit to:
    • Inform their families, friends, and co-workers of their intention to quit smoking and request their understanding and support.
    • Remove cigarettes from their environment. Before attempting to quit, they should consider avoiding smoking in places where they spend a lot of time (eg, home, car).
    • Review previous quit attempts. What helped? What led to relapse?
    • Anticipate challenges to the planned quit attempt, particularly during the critical first few weeks. These challenges include nicotine withdrawal symptoms.
  • Encourage Nicotine Replacement Therapy (NRT): Tables 60.2, 60.3, 60.4, 60.5, 60.6, and 60.7 present information related to pharmacologic aids to smoking cessation.
  • Provide key advice on successful quitting:
    • Abstinence -- Total abstinence is essential. "Not even a single puff after the quit date."
    • Alcohol -- Drinking alcohol is highly associated with relapse. Persons who stop smoking should review their alcohol use and consider limiting/abstaining from alcohol during the quit process.
    • Other smokers in the household -- The presence of other smokers in the household, particularly a spouse, is associated with lower success rates. Patients should consider quitting with their significant others and/or developing specific plans to stay abstinent in a household where others still smoke.
  • Referral: Consider referring patients to a group clinic or intensive smoking cessation program. Information on reputable programs can be obtained by calling the National Cancer Institute Information Service: (800)4-CANCER.
  • Provide self-help materials (see Patient Resources).

6.

Schedule follow up contact:

  • A member of the office staff should call or write patients within 7 days after the quit date. A second follow up contact is recommended within the first month. Schedule further follow up contacts as indicated.
  • Actions during follow-up:
    • Congratulate success
    • If smoking occurred, review circumstances and elicit recommitment of total abstinence. Remind patient that a lapse can be a learning experience. Identify problem areas already encountered and anticipate challenges in the immediate future. Assess NRT use and problems. Consider referral to more intense or specialized program.

Table 60.1. Smoking Assessment Form.

Table

Table 60.1. Smoking Assessment Form.

Table 60.2. Availability of Pharmacologic Agents for Smoking Cessation.

Table

Table 60.2. Availability of Pharmacologic Agents for Smoking Cessation.

Table 60.3. Information About Nicotine Patch Use.

Table

Table 60.3. Information About Nicotine Patch Use.

Table 60.4. Information About Nicotine Gum Use.

Table

Table 60.4. Information About Nicotine Gum Use.

Table 60.5. Information About Nicotrol® Inhaler Use.

Table

Table 60.5. Information About Nicotrol® Inhaler Use.

Table 60.6. Information About Nicotrol® Nasal Spray (Nicotrol® NS) Use.

Table

Table 60.6. Information About Nicotrol® Nasal Spray (Nicotrol® NS) Use.

Table 60.7. Information About Use of ZybanTM (Bupropion Hydrochloride) Sustained-Release Tablets.

Table

Table 60.7. Information About Use of ZybanTM (Bupropion Hydrochloride) Sustained-Release Tablets.

Creating a Smoke Free Office: 2

  • Select a date for the office to become smoke-free. Advise all staff and patients of this plan.
  • Post no-smoking signs in all office areas.
  • Remove ashtrays.
  • Display nonsmoking materials and cessation information prominently.
  • Do not use waiting room magazines that contain tobacco advertising. A list of such magazines is available (Glynn and Manley, 1995; Goldsmith, 1991).

Patient Resources

  • Smoking: Steps To Help You Break the Habit. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org
  • How to Quit Cigarettes; The Fifty Most Often Asked Questions about Smoking and Health and the Answers. To order these and other materials, contact your local office of the American Cancer Society or call (800)ACS-2345.
  • Smoking in Women. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Smoking Can Really Do a Number on Your Health. To order this and other material, contact the American Dental Association, Department of Salable Materials, 211 E Chicago Ave, Chicago, IL 60611; (800)947-4746.
  • Chew or Snuff Is Real Bad Stuff; Why Do You Smoke? National Cancer Institute. Superintendent of Documents, Consumer Information Center — 3C, PO Box 100, Pueblo, CO 81002.
  • Check Your Smoking I.Q.: An Important Quiz for Older Smokers. To order this and other material, contact the National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish); Internet address: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm
  • You Can Quit Smoking: Smoking Cessation Consumer Guide, Clinical Practice Guideline Number 18. Publication number 96-0695. Call or write: Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring MD 20907; 1-800-358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions); Internet address: http://www.ahcpr.gov

Provider Resources

  • Stop Smoking Kit. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000; Internet address: http://www.aafp.org
  • Smoking and Reproductive Health. American College of Obstetricians and Gynecologists, 409 12th St SW, Washington, DC 20024; (800)762-2264. Technical Bulletin AT180.
  • Doctors Helping Smokers. To order this office-based tobacco cessation program and video by the same name, contact Doctors Helping Smokers at Blue Plus, PO Box 64179 R 3-11, St. Paul, MN 55164; (800)382-2000, ext 1975.
  • How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians; How To Help Your Patients Stop Using Tobacco: A National Cancer Institute Manual for the Oral Health Team. To order these and other materials, contact the Office of Cancer Communications, National Cancer Institute, Bldg 31, Room 10A16, Bethesda, MD 20892; (800)4-CANCER; Internet address: http://cancernet.nci.nih.gov
  • Helping Smokers Quit: A Guide for Primary Care Clinicians, Clinical Practice Guideline No. 18, AHCPR Publication No. 96-0693. Call or write: Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; (800)358-9295, Also available through InstantFAX at (301)594-2800 (push 1 and start, wait for directions); Internet address: http://www.ahcpr.gov
  • Nurses: Help Your Patients Stop Smoking. National Heart, Lung, and Blood Institute Smoking Education Program, PO Box 30105, Bethesda, MD 20824-0105; (301)251-1222 (English and Spanish); Internet access: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American College of Obstetricians and Gynecologists. Smoking and Reproductive Health: ACOG Technical Bulletin . 1993; 180:1–5.
  4. American College of Physicians, Health and Public Policy Committee. Methods for stopping cigarette smoking. Ann Intern Med . 1986; 105:281–291. [PubMed: 3729208]
  5. American Medical Association. How to help patients stop smoking: guidelines for diagnosis and treatment of nicotine dependence . Chicago, Ill: American Medical Association, 1994.
  6. Canadian Task Force on the Periodic Health Examination. Prevention of tobacco-caused disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 43.
  7. Centers for Disease Control. The Health Benefits of Smoking Cessation . Washington, DC: US Department of Health and Human Services; 1990. USDHHS publication CDC 90-8416.
  8. Centers for Disease Control, Office on Smoking and Health. The Health Benefits of Smoking Cessation: A Report of the Surgeon General, 1990 at a Glance . Rockville, Md: Centers for Disease Control; 1990. USDHHS publication CDC 90-8419.
  9. Fiore MC. The new vital sign: assessing and documenting smoking status. JAMA . 1991; 266:3183–3184. [PubMed: 1823545]
  10. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1996. AHCPR Publication No. 96-0692.
  11. Fiore MC, Jorenby DE, Baker TB, Kenfor SL. Tobacco dependence and the nicotine patch: clinical guidelines for effective use. JAMA . 1992; 268:2687–2694. [PubMed: 1304736]
  12. Frank E, Winkleby MA, Altman DG, Rockhill B, Fortmann SP. Predictors of physicians' smoking cessation advice. JAMA . 1991; 266:3139–3144. [PubMed: 1956100]
  13. Glynn TJ, Manley MW. How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians . Bethesda, Md: National Institutes of Health; 1995. NIH publication 95-3064.
  14. [No Authors Listed] Magazines without tobacco advertising (Medical News and Perspectives) JAMA . 1991; 266:3099–3102. [PubMed: 1956088]
  15. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Smoking cessation: attributes of successful interventions. JAMA . 1988; 259:2883–2889. [PubMed: 3367456]
  16. Solberg LI, Maxwell PL, Kottke TE, Gepner GJ, Brekke ML. A systematic primary care office-based smoking cessation program. J Fam Pract . 1990; 30:647–654. [PubMed: 2345333]
  17. Steenland K. Passive smoking and the risk of heart disease. JAMA . 1992; 267:94–99. [PubMed: 1727204]
  18. US Preventive Services Task Force. Counseling to prevent tobacco use.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 54.

Footnotes

1

Adapted from: Fiore MC, Bailey WC, Cohen S.J., et al. Smoking Cessation. Clinical Practice Guideline No 18. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1996. AHCPR publication 96-0692.

2

Adapted from: Glynn TJ, Manley MW. How To Help Your Patients Stop Smoking: A National Cancer Institute Manual for Physicians. Bethesda, Md: National Institutes of Health; 1995. NIH publication 95-3064,