Smoking Cessation

• Patients who smoke should receive advice and encouragement to stop at every visit.

• Take advantage of the teachable moment, when a patient who smokes is being treated for any medical condition.

• Multiple strategies and persistence are usually needed for successful cessation because tobacco dependence is a chronic disease.

• Brief counseling, usually lasting less than 3 minutes, is an effective way to begin intervention.

Family physicians are in a unique position to assist their patients in smoking cessation. Because 7 of every 10 smokers visit their physician at least once a year, this is a golden opportunity that should not be missed. Among smokers, 70% want to quit and about 40% make an attempt each year, but less than 5% succeed. Even brief physician advice can double the quit rate (Fiore et al.,

2008). Of those who try to quit on their own and do not use recommended cessation methods, most relapse within 8 days (CDC, 2008).

A survey by the Association of American Medical Colleges (AAMC, 2007) about physician behavior related to smoking cessation is summarized as follows:

Most physicians consistently ask patients who smoke about their smoking status and advise them to stop (86%), but only 13% say they usually refer smokers to others for appropriate treatment and only 17% say they usually arrange for follow-up visits to address smoking. Only 31% "usually" advised use of nicotine replacement therapy, and 25% "usually" prescribed other medication for cessation. Only 7% regularly referred patients to a quit line.

Physicians regard current smoking cessation tools as inadequate, citing the following:

• Insufficient services, resources, and organizational support

• Interventions that have only limited effectiveness

• Limited education and training for physicians on addressing tobacco use and cessation interventions

The five factors cited most often by physicians as significant barriers to successful interventions are lack of patient motivation (63%), limited coverage for interventions (54%), limited reimbursement for a physician's time (52%), time with patients is limited (41%), and too few available cessation programs (39%).

Patients should be asked about tobacco use at every visit because repeated screening increases rates of clinical intervention. Tobacco users should be advised to quit at every visit (SOR A), because there is a dose-response relationship between the number of contacts and abstinence. Tobacco use screening coupled with brief advice is one of the top-three clinical prevention measures and is cost-effective as well (Maciosek et al., 2006). Tobacco-cessation treatment may include a variety of components: counseling for behavior change in both individual and group settings, such as motivational interviewing and problem solving/skills training; use of evidence-based pharmacotherapy; and proactive telephone quit line counseling (Fiore et al., 2008; USPSTF,

2009). Patients should receive at least minimal advice and encouragement at every visit based on the five "As" approach (Box 50-2). The American Academy of Family Physicians (2005) has a campaign to encourage its members to engage themselves in smoking cessation interventions. Using two As, "Ask and Act," the AAFP program emphasizes brief counseling and effective follow-up.

Key Points

Box 50-2 Five As for Tobacco Users Willing to Quit

Ask about tobacco use at every visit.

Advise to quit through clear personalized messages.

Assess willingness to quit.

Assist efforts to quit.

Arrange follow-up and support.

As part of taking the history from a patient who smokes, clinicians should ask the following three questions to assess the patient's degree of nicotine addiction:

1. How much do you smoke? (How many cigarettes or cans of "dip" per day, for how many years?)

2. When do you smoke the first cigarette of the day?

3. How long is the period between cigarettes before craving another smoke?

Patients who smoke more than 20 cigarettes a day, who light their first cigarette within 30 minutes of waking, and who have cravings within 1 hour of the most recent cigarette are likely to have significant physiologic addiction to nicotine. Smoking fewer than 10 cigarettes a day suggests less addictive behavior, and a few patients report that they smoke only during social situations and only 5 to 10 cigarettes a week. Determining the patient's pattern of smoking will provide clues into the level of addiction.

Office spirometry to obtain a forced expiratory volume in 1 second (FEVj) can also be useful in motivating smokers to quit. Comparing the smoker's "lung age" to the age of a healthy individual who has the same FEVj, then showing the smoker a graphic display (Fig. 50-5, A), more than doubled the rate of quitting smoking after 12 months (13.6% vs. 6.4%) (Parkes et al., 2008). For example, a 52-year-old smoker with a 20-pack-year history (1 pack/day for 20 years) may have the lung age of a 75-year-old. Probable age at disability and death if the person continues smoking or stops smoking can be shown (Fig. 50-5, B). Such a visual presentation is often effective in achieving cessation even if smokers have a normal lung age because they may think it is not too late for them to quit.

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