Smoking Cessation Management Overview for Healthcare Providers
Tobacco abuse is the leading preventable cause of mortality, and smokers who are successful in cessation significantly reduce their risk of development of or dying from diseases that are related to tobacco use. When asked, approximately 70% of smokers express the desire to quit smoking, and over 50% have attempted smoking cessation within the past year. The USPHS guidelines recommend that clinicians assess tobacco use and provide tobacco cessation interventions when applicable at every visit. There is clear evidence that even brief clinician advice interventions on smoking cessation (less than 5 minutes) at every encounter can increase cessation rates.
Identify Smokers in Your Practice and Assess Readiness to Quit
The use of the 5 A’s (Ask, Advise, Assess, Assist, Arrange) can assist the clinician in identifying smokers in their practice as well as provide simple steps to aid those patients in successful smoking cessation. The 5 A’s are as follows:
- ASK patients about smoking.
A full assessment of tobacco use should be made including the frequency of use, products used, the degree of nicotine dependence, history of previous attempts at cessation (include prior methods and their effectiveness). Dependence on nicotine can be estimated from the duration of smoking history, number of cigarette smoked daily, as well as how soon after waking up to smoker has the first morning cigarette. Degree of nicotine dependence predicts the difficulty that patient will have with smoking cessation methods. Smokers with high dependence start smoking early in life, have smoked for many years, smoke more cigarettes daily, and smoke their first cigarette within the first 30 minutes of awakening.
- ADVISE all smokers to quit.
No amount of tobacco use is considered safe. Clear evidence is available that brief clinician advice interventions to quit (less than 5 minutes) at each office visit can increase smoking abstinence rates. Not every patient will be willing to proceed with smoking cessation, but these brief interventions with advice to quit over time can promote the patient’s motivation to stop smoking.
- ASSESS their readiness to quit.
Assess the patient’s willingness to quit smoking. Understanding the patient’s perspective is imperative to the success of amoking cessation assistance. The Stages of Change model describes the process by which behavior change occurs. It identifies five stages through which smokers are hypothesized to progress as they moved from smoking to abstinence: pre-contemplation (not ready to quit), contemplation (considering adequate attempt), preparation (actively planning adequate attempt), action (actively involved in a quit attempts), and maintenance (achieved smoking cessation). Not every smoker will have predictable behavior change, however the basic concept of gradual change is useful for clinicians when discussing smoking cessation. An alternative approach may include proactively offering treatment to all smokers.
- ASSIST them with their smoking cessation effort.
Once the patient has expressed a motivation to quit smoking, the clinician should ensure that adequate resources are available to aid in their cessation efforts. Assessing the tolerability and effectiveness of prior cessation methods, if applicable, is essential to frame recommendations for the current cessation attempt. Identifying barriers and triggers as well as counseling the patient on symptoms of nicotine withdrawal should be included in the initial consult.
- ARRANGE follow up visits or contact.
Congratulate your patient on their success and encourage continued abstinence due to high risk of relapse. Relapse prevention should be part of every encounter with the patient he has recently quit smoking. It is recommended that patients be followed for at least 3 months after quitting, as the risk of relapse is highest during this period. If the patient is on pharmacologic therapy, assess for compliance, side effects, and efficacy. Re-emphasize available support resources.
Help Your Patient Choose Their Method
When assisting your patient to identify their method of cessation, consider the following factors:
- Has your patient tried any cessation methods, and if so what was their experience?
If the patient has had sustained response to prior methods, repeat treatment may be indicated. Assessment of the tolerability of prior methods as well as the failure rates on prior methods should also be assessed when choosing a smoking cessation aid.
- Which method is practical for your patient?
To ensure success of your patient’s smoking cessation method, it should be determined whether that method is practical and/or affordable for the patient. Consideration should include health insurance coverage, out of pocket cost, and likelihood of adherence to the particular method chosen. For example, medical co-pays may be too expensive for your patient on certain pharmacologic therapies, or your patient may not carry prescription insurance. Nicotine Replacement Therapy (NRT), though available over-the-counter, can also be expensive for those on a limited budget. Patients with dentures would be unlikely to be able to use NRT gum, and those with a history of dermatitis or adhesive allergy may not be able to use the topical NRT.
- Is your patient a light smoker?
A light smoker is defined as someone that smokes less than 10 cigarettes per day. Behavioral therapies are first-line treatment for light smokers, but pharmacotherapy can also be offered. It is suggested that nicotine replacement therapy be started at a lower dose in light smokers.
- Does your patient plan to use their cessation method long-term (>14 weeks)?
Long-term use of smoking cessation aids can be helpful in smokers who have persistent withdrawal symptoms during the course of medication, have relapse in the past after stopping medication, and/or those who desire long-term therapy. A small percentage of smoker successfully quit using nicotine replacement medications on a as needed basis long-term.
The use of nicotine replacement therapy for up to 6 months does not present a known health risk and dependencies are uncommon. The FDA has approved the use of Zyban, Chantix, and some nicotine replacement therapies for up to 6 months use.
- Is your patient male or female?
There is mixed evidence that nicotine replacement therapy may be less effective in women than men, which may lead clinicians to recommend the addition of prescription medications in females. Analysis of the data available, however, indicates that nicotine replacement can be effective in both sexes.
- Is your patient concerned about weight gain?
A significant percentage of patients will experience weight gain following smoking cessation. Zyban and nicotine replacement therapy, in particular 4 mg nicotine gum and 4 mg nicotine lozenges, can DELAY but do not PREVENT weight gain.
- Are you considering treating your patient with combination therapy?
Combined use of the nicotine replacement patch long-term (greater than 14 weeks) with breakthrough methods (nicotine gum, nasal spray, lozenges) or Zyban increases long-term abstinence rates when compared with placebo.
The combination of counseling and medication is more effective for smoking cessation that either medication or counseling alone. Medications alone induce an average abstinence rate of 21.7%. Medications in combination with counseling produce an average abstinence rate of 27.6%. Higher numbers of counseling sessions in combination with medications produce the highest abstinence rates:
- 0-1 Sessions 21.8%
- 2-3 Sessions 28%
- 4-8 Sessions 26.9%
- >8 Sessions 32.5%
- Does your patient have cardiovascular disease?
Continued cigarette use is a major risk factor for cardiovascular events in those with cardiovascular disease (CVD). Smoking cessation is particularly beneficial in this population. Management of smoking cessation in this population is similar to those without CVD. In those patients with stable CVD, we suggest the same treatments as those in the general population.
Nicotine replacement and Zyban have been proven to be safe in this setting.
Initiation of nicotine replacement therapy in those with acute coronary syndrome is not advised until these patients are deemed stable and asymptomatic. Though there are significant benefits to smoking cessation in this population, and this likely outweighs risks of continued cigarette use, it is recommended that this be reviewed on a case by case basis by the treating provider.
- Does your patient suffer with a psychiatric illness?
Smoking is highly prevalent among patients with mental illness, and while there is concern that cessation may exacerbate some psychiatric illness, evidence indicates that this is not true. Behavioral and pharmacologic therapies can increase smoking cessation rates in those with psychiatric illnesses. The choice of pharmacologic therapy may vary with the underlying psychiatric illness and current medications.
Review of Smoking Cessation Methods
Currently, the following smoking cessation methods have been studied and found to be successful in certain populations:
- Cold turkey (Only successful in <5% of cases)
- OTC medications
- Prescription medications
- Individual and/or group couseling support
- Quit lines
Pharmacologic therapies include the following (Please refer to updated prescribing information for dosing and schedule):
- OTC Medications
- Nicotine Replacement Therapy (NRT)
- Transdermal patch, Gum, Lozenges
- Nicotine Replacement Therapy (NRT)
- Prescription Medications (1st Line)
- Nicotrol inhaler
- Zyban (bupropion SR)
- Chantix (varencicline)
- Prescription medications (2nd Line)
Individual or Group Counseling Support
Forms of counseling and group support should be made available to smokers who have decided to quit. Those with high dependency or those with a failed smoking cessation attempts should always be offered counseling and group support resources in combination with smoking cessation aids. Counseling can help the patient identified overcome situations that trigger the urge to smoke, and support groups provide encouragement through regularly scheduled meetings with persons who are also attempting to quit. Research shows that success rates of all smoking cessation methods are substantially higher when combined with a support program such as counseling, group meetings, or quit lines.
Quit lines are free, telephone based counseling programs that are available nationwide. When your patient contacts a quit line, he or she is introduced to a trained counselor who can assist them in developing a strategy for quitting as well as motivate them to continue the method that they have chosen. In many cases, counselors can provide material that improve your patient’s chances of quitting. Examples of resources available are:
- National Cancer Institute Smoking Quit Line
- 1-877-44U-QUIT (1-877-448-7848)
- National Quit Line
- 1-800-QUITNOW (1-800-784-8669)
- Smokefree TXT
- Smokefree TXT is a mobile service created to provide 24/7 encouragement, advice, and tips to help your patient stop smoking for good. TEXT the word QUIT to IQUIT (47848) from a mobile phone, answer a few questions, and the patient will start receiving messages (messaging fees may apply).
- Smartphone Applications
- NCI QuitPal
- Quit Guide
The Patient with Relapse
Over 60% of smokers who relapse report the desire to quit again within one month. Remind your patient that most smokers require multiple attempts at smoking cessation before they are successful. Patients with relapse have often attempted smoking cessation “cold turkey” or on pharmacologic therapy without the addition of behavioral support. Those attempting to quit without pharmacologic support or counseling are only successful less than 5% of the time.
If your patient has relapsed while on pharmacologic therapy, consider the addition of behavioral support and/or referral to a subspecialty clinic for smoking cessation program. Patients with heavy dependence on nicotine or patients who have failed with multiple attempts may require one on one specialized counseling. Involving different types of providers through a multidisciplinary approach (physicians, nurses, psychologist, dentists) can also increase cessation rates in those with relapse.
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