Smoking Cessation



Smoking Cessation



James B. Froehlich


Tremendous progress has been made in reducing the incidence of tobacco abuse. This is partly the result of the health care profession educating and counseling smokers, but is also undoubtedly related to the increasing inconvenience and social stigma of smoking. The rising cost of cigarettes and the increasing prohibitions against smoking in public places have clearly been shown to decrease the incidence of smoking. Although the problem of tobacco abuse has seen much improvement in the last 50 years, with the prevalence of smoking decreasing by about half in the past 50 years, tobacco abuse remains the largest preventable cause of death in the United States. It is estimated that roughly a third of cancer and cardiovascular deaths, and virtually all of the chronic obstructive pulmonary disease (COPD)-related deaths, can be attributed to tobacco abuse. It is estimated that the cumulative impact on our economy, in terms of health care costs and lost productivity, approaches $200 billion per year.


The opportunity for affecting patients’ behavior through interaction that is inherent in the health care system is significant. Most smokers see a primary care physician each year and can be identified with the routine inclusion of tobacco use as one of the vital signs. In spite of this opportunity, treating tobacco dependence remains challenging. Most smokers are not ready or interested in quitting at any given time. This may be partly because of the high failure rate of unaided, cold turkey attempts to quit smoking. However, successful interventions to treat smoking patients are clearly possible.


A great deal is known about the science of smoking cessation. It is important to understand some of these basic facts and to approach smoking cessation in an organized fashion based on these principles. Smoking remains the leading cause of avoidable death in the United States. Most smokers are not asked about, or counseled about, smoking when they are seen in the health care setting, and these interactions are poorly documented. The rate of recidivism among those who attempt to quit smoking is high initially, but a number of interventions, including counseling and repeated attempts, can improve this. Patients who are willing to quit smoking should be identified, because they have the best chance of quitting smoking. Counseling plays an important role in the treatment of smokers, both in trying to recruit those who are unwilling to quit and in supporting and improving the chances of quitting among the willing. Pharmacologic interventions, including nicotine-replacement therapy, have been shown to improve likelihood of smoking cessation.



Identifying Smokers


The first, and therefore most important, therapeutic intervention is the interview about smoking history. Most smokers see a care provider at least once a year. The physician visit is an opportunity to identify smokers and begin evaluating them for willingness to quit, initiate counseling to encourage willingness to quit, discuss options to achieve smoking cessation, and effect referral to smoking-cessation ancillary services to begin smoking-cessation therapy. To this end, every patient encounter should inquire about smoking status and willingness to quit. It should also be noted that most providers either fail to pursue a smoking history or fail to document this. It is increasingly considered a metric of care quality to document smoking history and attempts to intervene for smoking cessation.



Motivating Patients to Quit


A motivational interview geared to encourage and recruit smokers to quitting can increase cessation rates by as much as 30%. Even without the extended training and patient interface time required for true motivational interviewing, an abbreviated format, which focuses on the five Rs, can make clinical encounters more effective and result in higher rates of smoking cessation. These counseling priorities focus on reasons to quit, risks associated with continued smoking, rewards for quitting, roadblocks to successful quitting, and repetition of counseling at each clinic visit.


Randomized studies have shown that a significant percentage of smokers can be recruited to quitting and that quit rates are much higher among this group. For those smoking patients unwilling to pursue quitting, a number of approaches should be used. It is important to encourage those unwilling to quit to decrease smoking as much as possible. It is also felt to be effective to recommend nicotine-replacement therapy, such as nicotine patch or gum, even before attempts at smoking cessation are made. The provider should express acceptance of the patient’s reluctance to quit, but informational support, as well as an empathic, supportive discussion, is a recommended strategy. Finally, it is important to reduce barriers to treatment as much as possible. Arranging prompt follow-up, making repeated offers to assist in quitting, and making smoking-cessation counseling available within the same facility as patient visits can all make smoking cessation more likely to occur. The combination of motivational interviewing, smoking reduction, and nicotine-replacement therapy is thought to increase the chances of successful quitting (Figure 1).


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FIGURE 1 Approach to a smoker unwilling to quit. EMR, electronic medical record. (From Fiore MC, Baker TB: Treating smokers in the health care setting, N Engl J Med 365:1222–1231, 2011.)

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Aug 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Smoking Cessation

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