Clinical Review

Smoking cessation: Tactics that make a difference

Author and Disclosure Information

Telephone “quitlines,” Web support, text messaging, and drugs all boost the quit rate—if you set the stage


 

References

This research is supported by the Intramural Research Program of the NIH, National Institute on Drug Abuse. The author has no other financial relationships relevant to this article.
Practice recommendations
  • Recommend that your patients take advantage of telephone counseling—it improves both the quit rate and the long-term abstinence rate. Web-based cessation programs also support smokers in all stages of quitting.
  • Encourage patients to use both pharmacotherapy and counseling to improve abstinence. Several medications—including bupropion and varenicline—achieve comparable rates of quitting and long-term abstinence.
  • Train your office staff to help identify and counsel smokers.

CASE Smoker who uses OCs

Ann G. is a 34-year-old mother of two who has been coming to the office for her annual Pap smear for several years. Her medical history is significant only for her vaginal deliveries and mild gastroesophageal reflux. She takes oral contraceptives (OCs) and uses over-the-counter ranitidine hydrochloride (Zantac) as needed. On Ann’s most recent annual visit, the medical assistant, Tammy, takes her vital signs. The chart has a section about smoking status, and Tammy notes that Ann is a smoker.

During the office visit, the ObGyn explains to Ann that her smoking is a serious health risk and advises her to quit. She also informs Ann that she needs to find a new form of birth control next year, as smoking increases the risks of using OCs, especially after age 35. Ann nervously laughs off the warning.

When she returns the following year, Ann confesses to Tammy that she is still a smoker. When Tammy asks about quitting, Ann remains adamant: “No way—I can’t do it.” Nonetheless, during the office visit, the ObGyn raises the subject again, and Ann admits that she is afraid that quitting smoking will cause her to gain weight. The physician attempts to address Ann’s fears, talks about other birth control options, and gives her a 3-month prescription for OCs. Before ending the visit, the ObGyn tells Ann that they will discuss what to do about birth control when she returns in 3 months.

Ann faces an uphill battle. The amount of nicotine in cigarettes is increasing,1 making it harder to quit. The good news is that the treatment of tobacco addiction is constantly improving, and the number of tools in our arsenal is growing. In fact, there are many resources that we can try before turning to the prescription pad. However, when needed, pharmacotherapy is an important adjunct in a patient’s struggle to achieve abstinence.

“5-A” strategy sets stage for success

Treating Tobacco Use and Dependence, a useful publication from the Agency for Healthcare Research and Quality (AHRQ), offers guidelines on many aspects of tobacco cessation, from counseling to pharmacotherapy to reimbursement.2,3 The guidelines break the smoking cessation process into five A’s:

  1. Ask each patient about her smoking status.
  2. Advise each patient who smokes that she needs to stop smoking.
  3. Assess your patient’s willingness to make a quit attempt in the next 30 days.
  4. Assist your patient in making this quit attempt or encourage her to consider a quit attempt later.
  5. Arrange close follow-up of any quit attempts to help prevent relapse.
The Ask and Act program from the American Academy of Family Physicians outlines a similar strategy.4 The program instructs physicians to Ask every patient about her tobacco use and to Act to help her quit, via on- or offsite counseling, telephone “quitlines,” patient education materials, self-help guides or Web sites, cessation classes, and pharmacotherapy.

Take advantage of every opportunity you have to discuss the issue with patients; short conversations can make a difference. A Cochrane review of 39 trials including 31,000 smokers revealed that even brief advice—simply encouraging patients to quit—was statistically significant in helping the smoker quit (odds ratio [OR]=1.74; 95% confidence interval [CI], 1.48–2.05).5 The pooled data generated a quit rate difference of 2.5%: for every 40 people who were told to quit, one more smoker would.

Empower the office staff

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