Tobacco Use and Cessation
The negative health effects of
tobacco use are legion, claiming over 400,000 lives in the United States each
year, and many more in the rest of the world. Although tobacco use is
surprisingly high in prevalence, and opportunities for clinical intervention
are frequent, health care clinicians have not historically intervened in a
consistent and effective manner with their patients who smoke. Until quite
recently, only half of the smokers interviewed in primary care clinics reported
that a clinician had asked about their smoking,
and of those, only a very small number
were given advice and assistance in quitting.
Several hypotheses could
account for lackluster performance of clinical tobacco intervention. If smoking
cessation interventions were ineffective, or were perceived by the majority of
clinicians as ineffective, there would be little motivation to use them. A good
deal of the published research on smoking cessation has been performed in
specialized smoking cessation clinics, using intensive interventions that
require much more time than the typical primary care visit; if this were the
only way to achieve
smoking cessation success, it would hold little appeal
for busy primary care clinicians. Yet another hypothesis holds that clinicians
know what is effective, and would be willing to offer such services, but
institutional or administrative barriers prevent delivery of optimal smoking
A 2-year project, initiated late in 1993 by the Agency for Health
Care Policy and Research (AHCPR), set out to address these hypotheses by
identifying effective, experimentally validated smoking cessation treatments
The final product, the
Smoking Cessation Clinical Practice Guideline, made specific, evidence-based recommendations for primary care
clinicians; smoking cessation specialists; and health care administrators,
insurers, and purchasers. It provided strong evidence that clinical tobacco
intervention is effective, can be done successfully at a wide range of
durations and intensities, and should receive specific health care system-level
support. Before turning to the specific conclusions of the Guideline, it is
important to note the evidentiary process that produced them.
BASIS FOR THE GUIDELINE
One of the first tasks the Guideline panel faced was developing a
set of a priori criteria to define the evidence that would form the basis of
subsequent meta-analyses. A survey of bibliographies and computer databases
revealed over 3,000 articles published from 1975 to 1994 related in some way to
smoking cessation. Evidence to be included had to report the results of a
randomized, controlled trial of a tobacco-use cessation intervention; provide
results on follow up at least 5 months after the quit date; be published in a
peer-reviewed journal; be published in English; and fall within the 1975 to
1994 (inclusive) review period. Only about 10% (slightly over 300) of
the articles reviewed met the inclusion criteria set by the panel.
For the articles that were selected, three independent reviewers
read the article and coded it on dimensions such as frequency and duration of
treatment, treatment outcome, control and intervention conditions, sample
sizes, and so forth. Once independent coding was complete, the reviewers met to
adjudicate any discrepancies in their coding; if this was not possible, the
discrepancy was resolved by a senior project staff member. One of the most
important measures produced by this coding was the effect of treatment, which
was represented as a modified intent-to-treat analysis. Here, all persons
randomized to a given treatment were used in the denominator, but only those
persons confirmed as abstinent were represented in the numerator. Given that in
virtually all studies some persons are lost to follow up, this represented a
conservative assumption that any person for whom no information was available
was classified as smoking. Studies that used biochemical confirmation of
self-reported abstinence from smoking were coded; it is interesting to note
using only biochemically confirmed outcomes did not
differ significantly from those studies lacking such confirmation.
Treatment effects and other
codes formed the basis for a dataset used in developing meta-analyses, which
produced logistic regression coefficients that were converted to odds ratios
(ORs). Significant meta-analytic results (i.e., significant ORs) formed the
basis for the Guideline recommendations. Once the Guideline panel created a
preliminary draft, copies were sent to 155 external peer reviewers for
evaluation on the grounds of validity, reliability, clarity, clinical
applicability, and utility. Following incorporation of the peer review
feedback, the final version of the Guideline was release in April, 1996. It
comprised six major recommendations:
- Effective smoking cessation treatments are
available, and every patient who smokes should be offered one or more of these
- It is essential that clinicians determine and document the
tobacco-use status of every patient treated in a health care setting.
- Brief cessation treatments are effective, and at least a
minimal intervention should be provided to every patient who uses tobacco.
- A dose-response relation exists between the intensity and
duration of a treatment and its effectiveness. In general, the more intense the
treatment, the more effective it is in producing long-term abstinence from
- Three treatment elements, in particular, are effective,
and one or more of these elements should be included in smoking cessation
- Nicotine replacement therapy
(nicotine patches or gum)
- Social support (clinician-provided encouragement and
- Skills training and problem solving (techniques on
achieving and maintaining abstinence)
- Effective reduction of tobacco use requires
that health care systems make institutional changes that result in systematic
identification of, and intervention with, all tobacco users at every visit.
ASKING ABOUT TOBACCO USE
The first task in any effective smoking cessation intervention is
to determine the target audience. Until recently, health care organizations
have been less than successful in consistently assessing and documenting the
tobacco use status of patients. A meta-analysis of nine studies on the effect
of clinic-wide smoking status screening systems indicated that in clinics where
a screening system was in place (compared with clinics where no screening
system was in place), the OR for clinician intervention increased threefold (OR
= 3.1, 95% CI = 2.2-4.2).
This dramatic increase in intervention
typically occurs without any special emphasis of the clinicians'
behavior, rather, it appears that having information
on tobacco use status available in a consistent and uniform manner is an
In addition to the dramatic increase in
rates of clinician intervention, there was a suggestion (not statistically
significant) that use of a screening system also increased cessation rates.
One simple and cost-effective
way to document tobacco use status is to include it as one of the vital signs.
The clinic staff member responsible for measuring blood pressure, pulse, and so
forth during clinic visits also asks the patient whether she or he is a
current, former, or never user of tobacco. This information can be captured on
preprinted progress note paper, a computer record, or by a vital sign stamp.
Other suggested methods involve stickers or other chart reminders.
It is important that the assessment be
done for every patient and at every visit. Because assessment of the
traditional vital signs is a routine part of medical practice, this screening
process takes virtually no time, and very little in the way of resources
(one-time development of a new progress note page or stamp).
ADVICE TO QUIT SMOKING
Once current smokers are identified by the screening process, the
next step is to provide a clear, strong, personalized message advising smoking
cessation. Each of the three components is important in making brief advice as
effective as possible. A clear message conveys the goal of becoming
tobacco-free; thinking about quitting sometime, or a reduction in smoking rate,
are only intermediate steps along the way. Clinicians should make their case as
strongly as possible. It is not an exaggeration to say that for patients who
smoke, eliminating tobacco is the single most important step they can take to
improve their health.
Probably the most important component of
brief advice is to personalize the message. It is difficult to imagine at the
end of the 20th century that many people could be unaware of the health effects
of tobacco use. For many people, though, the health risks are abstract
knowledge that are not considered to apply to them. Patients report that advice
from a clinician is an important factor in helping them decide to make a
stop-smoking attempt. Part of that influence comes from personal knowledge of
the individual's health history and familial risk factors. Insofar as possible,
tie the presenting complaint to the health effects of smoking (e.g., chronic
bronchitis, cardiovascular disease, management of asthma, diabetes). Some
patients may be fatalistic about their own health, but given information on the
effects of environmental tobacco smoke, will be willing to quit to protect the
health of nonsmoking partners, children, grandchildren, or even the family pet.
Even a very brief message that is clear, strong, and personalized
can have a positive effect. Seven studies involving brief physician advice of
less than 3 minutes provided data for a meta-analysis. Cessation rates in the
reference group, who received no advice, were 7.9%. Among those
receiving less than 3 minutes of physician advice, cessation rates were
10.2%, a statistically significant increase.
While this increment is not dramatic
in and of itself, it results from a very minimal
intervention. The cumulative effect of providing at least brief advice to all
patients who smoke, across the health care system, would results in thousands
of additional smoking cessation successes each year.
ASSISTING WITH THE SMOKING
Providing brief advice encouraging smoking cessation should be
considered a minimum standard of care provided to all patients identified as
smokers. Not all patients respond to the advice by agreeing to make a quit
attempt. Where there is no current motivation, it is sufficient to note that
the physician is available to assist in the future with a quit attempt, and
should check to see if the patient is ready at a future encounter. National
data suggest that 70% of persons who smoke would like to quit, so
chances are good that your brief advice may inspire a quit attempt.
In that case, there are several
additional steps physicians can take to assist patients in quitting
THE HUMAN TOUCH
Behavioral aspects of assisting smoking cessation attempts may be
classified into three general formats: self-help, individual counseling, or
group counseling. Based on national surveys of smoking cessation behavior, the
first of these appears to be most appealing to persons who smoke. The vast
majority of quit attempts in a given year are undertaken "cold
turkey", that is, without pharmacologic or behavioral assistance.
On the positive side, this requires
little in the way of treatment resources, such as clinic visits, medication
costs or copayments, or other professional fees, for the person attempting to
quit. Evidence suggests that only about 5% of those attempting to quit
this way are successful nonsmokers 1 year later.
Because many smokers may be inclined to
select less intensive treatments, the Guideline examined the efficacy of
various types of self-help materials, including those that could be used by
potential quitters who preferred not to seek additional treatment, or did not
have access to other smoking cessation treatments.
A meta-analysis of 25 studies examining various forms of
treatments compared 23 study arms, where no intervention was given (reference
group, with a 7.6% cessation rate and an arbitrary OR of 1.0), to eight
study arms using self-help interventions. The self-help OR was 1.2 (9.3%
cessation rate), but the 95% confidence interval estimate was 0.97 to
Because the interval includes 1.0 (the
reference OR), self-help interventions cannot be assumed to be significantly
different, in a statistical sense, from no intervention. A further
meta-analysis of 12 studies examined various types of self-help materials used
alone, including telephone helplines; video or audiotapes; lists of community
programs; and pamphlets, booklets,
and manuals. Of these, only telephone helplines showed
evidence of being effective on their own (OR = 1.4, CI = 1.1-1.8).
Because this OR was based on only three
study arms, the Guideline gave only modest endorsement to the efficacy of such
telephone support, pending a larger number of empirical findings of efficacy.
In clinical practice, self-help materials may be combined to increase their
effectiveness, as in the case where a patient is given a pamphlet, an
audiotape, and perhaps a list of treatment programs in the community.
While self-help materials
appear to have little or no significant effect on smoking cessation rates by
themselves, they should not be considered to be without value. These materials
can be very helpful in conveying information to patients in an efficient
manner, leaving the clinician more time to focus on critical issues. As an
example, a clinician might spend 10 minutes of an office visit describing the
nature and timecourse of nicotine withdrawal symptoms, leaving little or no
time to discuss coping with urges to smoke, or the proper use of smoking
cessation pharmacotherapy. The same clinician could provide the patient with a
pamphlet that covers nicotine withdrawal, and spend the time saved delivering
more effective interventions. As part of the Guideline process, a Consumer
You Can Quit Smoking) was developed in both English and Spanish, and is available from
the Government Printing Office.
The same meta-analysis that compared all self-help
interventions to the no-intervention reference group also examined the
effectiveness of individual and group counseling. Both types of counseling were
equally effective and more than doubled long term cessation rates, relative to
no intervention. The contrast with self-help alone interventions is striking.
Interpersonal contact appears to be a critical component of successful smoking
cessation efforts. Whether it is done one-on-one or in a group depends largely
on individual preferences and the availability of local resources.
A series of follow up meta-analyses examined components of the
intensity of treatment, for example, intensity of person-to-person counseling,
number of treatment sessions, and duration of therapy. As noted above, even
brief advice from a physician increased quit rates significantly, relative to
no advice. Meta-analyses of over 50 studies, however, suggested that the
optimal smoking cessation program involves 4 to 7 sessions of person-to-person
contact, spread out over a period of 8 or more weeks, with counseling sessions
lasting 10 minutes or more. Noting the results of these analyses suggested that
"more is more" when it comes to smoking cessation counseling, the
Guideline also stressed that very brief interventions are effective, and should
be considered as the minimum standard of care for all persons who smoke.
PERSON-TO-PERSON: WHO, WHAT, AND
Given the clear superiority of counseling treatments
-vis self-help treatments, the question of who should deliver
*The Government Printing office's telephone number
is (202) 512-1800.
arises. A large meta-analysis of 41 studies examined
the efficacy of various types of providers, relative to no provider (self-help
reference group). Physician providers were the most-studied (36 study arms) and
were quite effective in delivering smoking cessation interventions (OR = 1.5,
CI = 1.2-1.9). Nonphysician health care providers, a group that included
dentists, nurses, and pharmacists, were equally effective (OR = 1.4, CI =
1.1-1.8), as were nonmedical health care providers (psychologists, social
workers, counselors; OR = 1.8, CI = 1.5-2.2).
Thus, diverse groups of providers were
effective in helping patients quit smoking, relative to self-help
interventions, and no particular discipline was more effective than any other.
An interesting aspect of this meta-analysis was revealed in 14 study arms that
involved "multiple providers"; that is, interventions that were
delivered by clinicians of more than one discipline. The OR for the
multi-disciplinary approach was 3.8 (CI = 2.6-5.6), almost four times
more effective than self-help interventions, and twice as effective as a given
This is a strong endorsement of a
system-wide or team approach to smoking cessation. An example might be a clinic
where a medical assistant or nurse checks smoking status as part of the vital
sign, a physician provides brief advice and assistance for a quit attempt, a
pharmacist provides additional counseling while filling a prescription for
smoking cessation pharmacotherapy, and a psychologist or health educator
provides follow-up support.
Because individual and group counseling can vary widely in
content, additional analyses were undertaken to attempt to identify specific
types of treatment content associated with better long term cessation outcomes.
Eleven types of content, including cigarette fading, relaxation, exercise, and
diet, were entered into a meta-analysis of 39 studies. Two specific content
areas were significantly associated with higher smoking cessation rates. These
were problem solving/skills training (OR = 1.6, CI = 1.2-2.2) and
intratreatment social support (OR = 1.8, CI = 1.4-2.5).
Specialized smoking cessation programs
routinely incorporate these elements into treatment programs, but they can also
be incorporated into primary care practice to the extent that time allows.
The clinician begins by helping the patient set a quit date. This
should be a date ideally within the next 2 weeks that will optimize chances of
success. For example, if the person is in a smoke-free workplace from Monday
through Friday, a quit date at the beginning of the work week may take
advantage of a helpful environment. Conversely, if work is associated with
stress as a cue for smoking, quitting on a weekend or at the beginning of a
vacation may be preferred. If the date can be linked to a birthday,
anniversary, holiday, or other date with personal significance, so much the
better. The night before the quit date, all cigarettes in the person's
environment (e.g., home, car) should be located and destroyed. This includes
emptying ashtrays and checking clothing, bags, and other places where
cigarettes may have been forgotten.
Problem solving can be approached in at least two useful ways. One
is to ask the person to anticipate urge situations on and following the quit
date. A typical question might be, "When you think about a typical day,
when do you most want to smoke?" Typical
responses might include: when I first get up in the morning, on break at work,
after meals, when I'm driving, when I feel stressed, with a cup of coffee, the
end of the day. Knowing when urges are likely to arise, the person can plan
ahead to have something to distract her or him for the 2 to 3 minutes the urge
is likely to last. Distractions, or coping skills, may involve behaviors such
as leaving a situation, deep breathing, doodling on a piece of paper, or
sucking on a piece of hard candy. The critical feature is not the specific
coping skill chosen, but the process of anticipating urges and having a
distraction ready to use. Another way to elicit similar information is to ask
about past quit attempts (if any), and determine what was most difficult for
the individual, especially if it led to relapse to smoking. An example of the
latter might be alcohol use, a factor in a large number of relapses to smoking.
The person may need to plan on avoiding alcohol, or socializing in bars, for
several weeks following the quit date.
Intratreatment social support refers to the support and
encouragement provided by the clinician(s) involved in the smoking cessation
attempt. By asking about smoking status, giving brief advice, and working
collaboratively to assist the person in developing a quit plan, the
fundamentals of this support are already in place. Remember to be accepting of
the person's feelings, including ambivalence about quitting. The patient may
express doubt about her or his ability to stay quit, or mention things about
smoking that are enjoyable. Do not disparage these statements. Rather,
acknowledge them then redirect.
"Quitting smoking is seldom easy, but it seems
that you learned some valuable lessons from your last try, and you'll be
prepared for it this time around."
Additional information on providing support is
discussed later in the section on follow up.
Two additional treatment contents were examined in separate
meta-analyses: hypnosis and acupuncture. These types of treatment are popular
with some persons who smoke because of a perception that they work independent
of a personal motivation to stop smoking. For both hypnosis and acupuncture,
the available evidence was judged insufficient to assess effectiveness.
During the time period covered by the Guideline literature
review, two forms of nicotine replacement were approved as safe and effective
for smoking cessation by the United States Food and Drug Administration (FDA):
nicotine gum and the nicotine patch. Unlike the other aspects of clinical
intervention assessed by the Guideline, several published meta-analyses existed
for both forms of nicotine replacement therapy. These formed the basis for the
One important conclusion drawn by the
Guideline panel was that nicotine replacement therapies generally increase
rates of smoking cessation. As such, the Guideline recommended that such
therapies be offered to
all smokers motivated to make a quit attempt, in the absence of specific
Such circumstances included pregnancy
(where cessation using purely behavioral means should be attempted first), and
cardiovascular disease (e.g., within 4 weeks of a myocardial infarct, serious
arrhythmia, or severe or worsening angina pectoris). Since the publication of
the Guideline, a published report on a large number of veterans with current
cardiovascular disease suggested that nicotine patch therapy posed less risk of
adverse outcomes than continued smoking, suggesting that the latter
circumstance may be unnecessarily conservative.
Special circumstances notwithstanding,
there was no significant evidence that patients derive any benefit from trying
to quit without nicotine replacement therapy.
Of the two pharmacotherapies evaluated, the nicotine patch
(transdermal nicotine) was recommended as the treatment of choice for most
smokers. In part, this was caused by the efficacy of the patch. Five different
meta-analyses of nicotine patch efficacy, examining between 6 and 16 studies
each, found that relative to placebo, nicotine patches approximately doubled
long term abstinence rates (ORs = 2.1-2.6).
Treatment regimens of 8 weeks (varied by available doses) were recommended,
based on a meta-analytic finding that treatment periods of 8 weeks or less were
as efficacious as longer treatment periods.
The other reason for recommending the
patch was that it was more effective than placebo across a wide range of
psychosocial treatment intensities; that is, the patch was more likely to
produce long term abstinence than placebo, when used with treatments ranging
from brief advice to intensive group smoking cessation counseling. It is
important to note that as the more intensive behavioral treatments produced
greater absolute abstinence rates (as discussed above), the differential
between active and placebo quit rates was shifted upwards on the curve. The
effectiveness of the patch across a range of behavioral intensities may be
caused in part by greater ease of use, relative to nicotine gum.
Nicotine gum was also found to be an efficacious smoking cessation
therapy. Three recent meta-analyses found that active versus placebo gum odds
ratios at 12 months ranged between 1.4 and 1.6.
As noted in the discussion of the nicotine patch, the meta-analyses found that
active nicotine gum was much more effective when used with more intense
behavioral treatments than with brief advice. This may be caused by the
increased need to teach patients how to use nicotine gum effectively, in
comparison with the ease of use of the nicotine patch. Nicotine gum was
recommended in cases of patient preference, previous failure with the nicotine
patch, or specific contraindications to the nicotine patch (such as severe skin
reactions). A secondary recommendation was that more highly nicotine dependent
smokers (i.e., those smoking 20 cigarettes or more per day, who find it
difficult to refrain from smoking where it is prohibited, or who smoke within
30 minutes of rising) should use 4-mg gum rather
than the 2-mg dose.
The dosing flexibility of nicotine gum
may also be helpful with light smokers (those smoking 10 to 15 cigarettes per
Since the release of the Guideline, both 2-mg and 4-mg nicotine
gum, as well as two brands of nicotine patch (Nicoderm and Nicotrol), have
become available over the counter (OTC) in the United States. Although a
prescription is no longer required for these products, clinicians may use the
recommendations of the Guideline to suggest courses of treatment for patients
using OTC therapies. The clinician's role in providing support, information,
and skills training remains as vital as ever. It should also be noted that
pharmacotherapy meta-analyses did not support the use of either clonidine or
silver acetate for smoking cessation.
There were insufficient data available to
draw conclusions on the efficacy of antidepressants and
anxiolytics/benzodiazepines for smoking cessation.
To recap the steps of
assisting with a smoking cessation plan
- Set a quit date
- Make appropriate arrangements for pharmacotherapy, except
in special circumstances
- Help to anticipate difficult situations and plan alternate
- Provide social support for the quit attempt
As with all addictive behaviors, relapse (return to smoking) is
part of the clinical picture with smoking cessation. Even with the most
intensive treatments currently available, a large number of patients will
return to smoking within 6 to 12 months following the initiation of treatment.
Many of these eventual relapsers declare themselves early in the process; one
study found that of those persons having even a puff on a cigarette in the
first 2 weeks following their quit date, more than 80% were smoking at
the 6-month follow up point.
For this reason, the Guideline
recommends a follow-up contact within the first week following the quit date,
and if possible, a second contact within the first month. These contacts may be
either in-person visits or telephone calls.
The goals of follow-up contacts are designed primarily to
reinforce success in the recently quit smoker. Success should be praised, even
early in the process. For some people, 48 to 72 hours of abstinence may be a
personal best. It may be helpful to ask about the perceived benefits of being
smoke-free. Within a few days of quitting smoking, many people find their sense
of smell and taste improves. They may feel more in control of their lives, and
will certainly have extra money that is not being spent to buy cigarettes. If
possible, providing feedback on physical changes caused by smoking cessation
can be very helpful. Expired carbon monoxide levels drop to the level of never
smokers within 48 to 72 hours, and many people will experience decreases in
heart rate and blood pressure (although nicotine replacement therapy may affect
the latter two). Finally,
assess any current or anticipated difficulties related
to maintaining abstinence. If the patient reports increasing withdrawal symptom
intensity, it may be appropriate to consider an adjustment in pharmacotherapy
or referral to a support group. Encourage the patient to anticipate difficult
situations that may arise in the near-term future. An example of this would be
someone who quits smoking during the winter months, but who smoked heavily
while playing golf; as the golfing season approaches, urges to smoke may
reemerge, even if the person has been smoke-free for several months.
For persons who have returned to regular smoking, a different
approach is required. The most important determination to make is what their
current level of motivation is. Someone who is actively restricting their
smoking to a few cigarettes per day may be more willing to recommit to a new
quit date. For those who are unwilling to set a new quit date, convey the
message that you will be supportive when they are ready to try again. Relapse
prevention is an important goal of any smoking cessation intervention. However,
the extant literature lacks examples of interventions that have a sustained
positive influence on relapse. For this reason, the Guideline gave the weakest
level of evidentiary support to relapse prevention.
UPDATING THE AHCPR GUIDELINE
Innovations in smoking cessation treatment did not end in 1994
(at the end of the meta-analytic literature review), or with the publication of
the Guideline in 1996. In fact, the FDA approved nicotine nasal spray for
smoking cessation in the United States just weeks before the publication of the
Guideline in April, 1996. Since that time, the FDA has approved another
nicotine delivery system (the nicotine inhaler), and the first non-nicotine
smoking cessation therapy, bupropion SR (Zyban). Reports of success with
another antidepressant, nortriptyline, have been published.
At the time of this article's writing,
an effort is underway to update the AHCPR Smoking Cessation Clinical Practice
Guideline to encompass new findings in the literature from 1994 to the end of
1998. The update will certainly encompass the new pharmacotherapy options and
their integration into clinical practice. In addition, it will probably examine
behavioral interventions targeted at specific populations (pregnant women,
adolescents, etc.), and interventions designed at increasing the motivation of
persons not yet willing to make a quit attempt. The updated Guideline is
projected to be available during the first half of 2000.
PUTTING IT ALL TOGETHER
Primary care clinicians are uniquely situated to provide smoking
cessation advice and assistance to their patients who smoke. The following
steps, can help ensure that clinicians become successful at smoking
cessation counseling in their practices.
- Clinicians need to systematically identify all
tobacco users at every visit. This can be accomplished by using preprinted
progress note paper that includes tobacco status with the other vital signs, by
using a vital sign stamp that includes tobacco use status, or by stickers or
other chart reminders.
- Clinicians need to provide clear, strong and personalized
advice urging the smoker to quit. Even brief advice that is clear, strong and
personalized may be effective, especially if combined with an office-wide
approach where clinic staff reinforce the cessation message.
- Clinicians should identify smokers' current willingness to
quit and tailor assistance based on the patients' motivation. If a patient
seems willing to quit now, the clinician can provide assistance (see Step 4).
If an intensive treatment approach is needed, the clinician can refer the
patient to such a program or offer additional follow-up visits to provide the
intervention at the clinic. If the patient is not currently motivated to quit,
the clinician can tell the patient that the clinician will be available at
future visits to discuss smoking cessation when the patient is ready. In
addition, the clinician can enhance motivation by reviewing the long and short
term risks of smoking with the patient (long term risks are lung cancer; short
term risks are asthma exacerbations) as well as the long and short term rewards
of quitting (long term rewards are reduction of disease risks; short term
rewards are improved sense of taste and smell). Techniques to enhance
motivation include reviewing the Relevance of smoking cessation to the
individual smoker; long and short term Risks of smoking; and Rewards of
quitting. This message should be repeated to the smoker at each visit. (The 4
- The next step is assisting the motivated quitter. This
involves helping the patient devise a quit plan, including setting a quit date;
encouraging nicotine replacement therapy; giving key advice or "quit
tips"; and providing supplementary materials. In general, the more
intense the treatment and assistance, the more effective it is in producing
long term abstinence from tobacco use. In this regard, self-help materials are
the least effective means to promote success, and should be culturally,
racially and educationally relevant to the patient. At the other extreme, the
optimal smoking cessation program involves 4 to 7 visits of person-to-person
contact spread out over a period of 8 weeks, with counseling lasting 10 minutes
- Finally, clinicians should arrange follow-up with
motivated quitters as soon after the quit date as possible, preferably within
the first week. At this visit, clinicians should praise abstinence and give
anticipatory guidance regarding future difficulties with quitting
. Relapses can be addressed by letting the patient know
this is not a failure but a learning experience. Reviewing the circumstances in
which the relapse occurred and eliciting a renewed commitment to total
abstinence is important. If current problems such as withdrawal symptoms exist,
nicotine dosage can be adjusted.
At the end of the 20th century, tobacco use remains the leading
preventable cause of illness and premature death throughout North America.
Although there is room for improvement with smoking cessation therapies, there
exists a robust, empirically-validated strategy for helping patients
achieve a smoke-free future. At a minimum, all health
care providers can adopt the paired strategies of screening all patients for
tobacco use status and providing brief cessation advice to all persons who
smoke. With the addition of pharmacotherapy and person-to-person contact using
problem solving and social support approaches, cessation rates can be increased
by a factor of two or more. Investing a few minutes of time in smoking
cessation can result in significant improvements in life expectancy and quality
of life, a return few clinicians or patients would choose to ignore.
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