Smoking cessation: Tactics that make a difference
Telephone “quitlines,” Web support, text messaging, and drugs all boost the quit rate—if you set the stage
IN THIS ARTICLE
Enlisting the help of the office staff can have a significant impact on the health of patients. Fiore and colleagues evaluated a proactive approach in which medical assistants, while assessing smoking status, invited all smokers to participate in a cessation study.6 (The assistants received periodic thank-you gifts for their efforts.)
Participants were randomized to self-selected treatment or nicotine replacement therapy (NRT) patches, with or without a support program. Some who received the patches and support program also received individual counseling. The result: Most smokers were open to encouragement to quit smoking. The 13% point-prevalence abstinence rate 1 year out was comparable to the rate observed (14%) in smokers volunteering for NRT studies in the Cochrane review of 39 trials noted earlier.5
Likewise, in a randomized controlled trial (RCT) involving community-based primary care clinics, Katz and associates demonstrated that intake clinicians can also play an important role in smoking cessation.7 In the study, researchers trained intake clinicians (including registered nurses, licensed practical nurses, and medical assistants) to identify smokers, provide brief counseling, and assist in their preparation to quit. Patients were offered vouchers for patches and a counselor’s business card. Intake clinicians received periodic feedback on their performance based on exit interviews of the patients. These interventions had a statistically significant effect in moderate-to-heavy smokers in quit attempts, quit rates, and continuous abstinence.
CASE…continued A change of heart
At the 3-month follow-up, Tammy learns that Ann is still smoking—but she now wants to quit. Ann says that she found a pack of cigarettes in her 14-year-old daughter’s backpack, and feels that the only way to prevent her from getting hooked is to set a good example.
Tammy gives her the state’s quitline number, suggests some online quitting programs, and works with Ann to choose her target quit date and to pick the Web-based program she is going to use. Ann likes the fact that she can go online whenever she needs support. She also likes being able to put her quit date into the system so that the program will give her timely reminders of all her reasons to quit when she logs on.
The ObGyn writes prescriptions for varenicline (Chantix) and OCs and tells Ann to come back in 4 weeks. For her part, Tammy adds Ann to the list of patients she calls and will get in touch the day after Ann’s quit date. Tammy makes this her practice with patients because she knows that one well-timed phone call can be the key to a successful quit attempt.
Outside support improves abstinence rates
Improving your patients’ chances of long-term abstinence hinges, in part, on making the most of outside support. In many cases, your patients can take advantage of it without leaving their homes.
Quitlines increase quit rates, reduce relapse
Telephone counseling is an effective support system.8 Smokers who call to a single number (800-QUITNOW)—a service provided by the National Cancer Institute (NCI)—are directed to the quitline for their state. Smokers can also call the NCI directly at its quitline (877-44U-QUIT). Calling a quitline provides smokers with real-time counseling and information about how to quit smoking. Quitlines can be appealing to patients who are uncomfortable discussing their smoking in a group—and they are free to the patient.
Evidence supports the use of such help lines. In their study of the California Smokers’ Helpline, Zhu and colleagues tested a proactive protocol where smokers were funneled into a research trial when the help line was overwhelmed.9
The smokers in the treatment arm of this RCT were assigned a counselor who called the smokers as many as six times, following a relapse-sensitive schedule. The 12-month abstinence rate increased from 4.1% to 7.5% (P.001 in the group that had close telephone contact. this improved quit rate reflects both an increase percentage of smokers who and more importantly a decrease quitters relapsed.>
Another prospective RCT enrolled patients from Veterans Affairs (VA) medical centers and involved the same proactive telephone protocol that Zhu and associates used.10 The treatment group was offered telephone counseling as well as pharmacotherapy; the control group had access to the regular smoking-cessation program of the VA system. Quit rates were similar in both groups if the participant utilized both counseling and pharmacotherapy: 12.7% in the control group and 11.9% in the treatment group. However, only 18% of patients in the control group used both services. Among patients in the treatment group, 88% utilized both counseling and medication. This led to 6-month abstinence rates of 13% in the treatment group versus 4.1% in the control group (OR=3.5; 95% CI, 1.99–6.15). Patients who were directed to and enrolled in treatment programs were therefore more likely to attempt to quit and remain abstinent for up to 6 months.
