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NEW
APPROACHES TO HELP
PATIENTS STOP
SMOKING
BETHESDA,
MD--What
can physicians really do to help their patients quit smoking?
More than they may think, a new evidence-based guideline
suggests.[1]
The new guideline, released
by the US Public Health Service, describes current clinical
interventions for alleviating tobacco dependence. Titled
Treating Tobacco Use and Dependence, the document
updates a smoking cessation guideline released in 1996 by
the Agency for Healthcare Research and Quality (formerly,
the Agency for Health Care Policy and Research).
"The
new guideline provides information on innovative counseling
strategies that work, including telephone counseling and
other techniques," explained Michael C. Fiore, MD,
MPH, in a press briefing.[2] "It also contains evidence-based
information about the effectiveness of new medicines that
were not approved by the Food and Drug Administration when
the original guideline was issued, and [it] urges that every
tobacco user who is motivated to quit be provided with one
of these medicines in the absence of contraindications,"
said Dr. Fiore, who is head of the guideline panel and Director
of the Center for Tobacco Research and Intervention at the
University of Wisconsin Medical School in Madison.
BRIEF INTERVENTIONS
The guideline recommends a protocol of brief interventions for all physicians to use with their patients. The protocol begins with the "5 A's":
Ask
about tobacco use. Implement an officewide system
to identify and document tobacco use for every patient at
every visit.
Advise
patients to quit smoking. Use a clear, strong, and personalized
approach. An opening statement might be, "As your clinician,
I need you to know that quitting smoking is the most important
thing you can do to protect your health now and in the future.
The clinic staff and I will help you."
Assess
patients' willingness to stop smoking. If a patient is willing
to make an attempt at this time, provide support and assistance. Assist
the quit attempt by providing appropriate counseling and
pharmacotherapy. Set a quit date, ideally within two weeks.
Arrange
follow-up, preferably within the first week after the quit
date. A second follow-up within the first month is recommended.
Schedule further follow-ups as indicated.
The guideline recommends three types of counseling and behavioral therapies: helping smokers to recognize situations that increase the risk of relapse and to develop coping skills, providing social support as part of treatment, and arranging social support outside of treatment. The effectiveness of these treatments increases with minutes of contact.
PRESCRIBING PHARMACOTHERAPY
According to the guideline, almost all smokers trying to quit are candidates for pharmacotherapy. The exceptions include patients with medical contraindications, those smoking fewer than 10 cigarettes per day, pregnant/breast-feeding women, and adolescent smokers.
"We identified five first-line medications that reliably increase long-term quit rates," explained Dr. Fiore. "Only two of them, the nicotine patch and nicotine gum, were recommended in 1996. The new medications include the nicotine inhaler, the nicotine nasal spray, and the non-nicotine pill bupropion."
The data are insufficient for these agents to be ranked. Thus, the guideline recommends that the choice of first-line pharmacotherapy be guided by factors such as clinician familiarity, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy, and patient characteristics (eg, a history of depression or concerns about weight gain).
Clonidine and nortriptyline are appropriate second-line pharmacotherapies and should be considered for patients for whom first-line drugs are contraindicated or for those who are unresponsive to first-line medications, according to the guideline. Patients should be closely monitored for side effects associated with any antismoking agents.
The guideline advises that lighter smokers (those who smoke only 10 to 15 cigarettes per day) can often be treated with a lower dosage of the nicotine medications than is normally used. However, no dosage adjustments are required for sustained-release bupropion.
The guideline also suggests that long-term treatment (six months or more) may be appropriate for smokers who suffer from persistent withdrawal symptoms or who request long-term therapy. "The use of [nicotine replacement] medications long-term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication," the protocol states.
UNWILLING TO QUIT
The guideline points out that smokers unwilling to quit may lack specific information about the harmful effects of tobacco, may not have the required financial resources, or may be demoralized because of a previous relapse. In such cases, physicians should consider motivational intervention focused on the "5 R's":
Relevance:
Indicate to the patient why quitting is relevant to his
or her situation. According to the guideline, motivational
information "has the greatest impact if it is relevant
to a patient's disease status or risk, family or social
situation (eg, having children in the home), health concerns,
age, gender, and other important patient characteristics
(eg, prior quitting experience, personal barriers to cessation)."
Risks:
Ask the patient to identify potential risks of tobacco use;
highlight those that seem most relevant to the patient.
The guideline states, "The clinician should emphasize
that smoking low-tar/low-nicotine cigarettes or … [using]
other forms of tobacco (eg, smokeless tobacco, cigars, and
pipes) will not eliminate these risks."
The guideline also recommends that the clinician point out both the short and long-term risks of smoking.
Rewards:
Ask the patient to identify potential benefits of stopping
tobacco use, highlighting those of greatest relevance. Underscore
such benefits as improved health, improved sense of taste,
and cost savings.
Roadblocks:
Ask the patient to identify barriers or impediments to quitting
and cite aspects of treatment (eg, problem-solving, pharmacotherapy)
that can be used to address these barriers.
Repetition:
Repeat the motivational information every time an unmotivated
patient visits your office. According to the guideline,
"tobacco users who have failed in previous quit attempts
should be told that most people make repeated quit attempts
before they are successful."
--Stanley Nelson
References
1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco
Use and Dependence [Clinical Practice Guideline]. Rockville,
Md: US Department of Health and Human Services, Public Health
Service; June 2000.
2. Fiore MC. Treating Tobacco Use and Dependence: A
Public Health Service Practice Guideline [press briefing].
Washington, DC: US Public Health Service; June 27, 2000.
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Preventing
Relapse
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Because
of the chronic relapsing nature of tobacco dependence,
the guideline recommends offering relapse interventions.
Clinicians can institute either a minimal relapse prevention
program or a prescriptive plan. For example, in a minimal
program, the physician might:
- Congratulate the patient on any success in remaining
abstinent and encourage him or her to continue abstinence.
- Use open-ended questions designed to initiate
patient problem-solving. One such question might
be: "How has stopping tobacco use helped you?"
- Discuss the problems encountered or anticipated
threats to maintaining abstinence.
In
the prescriptive intervention, the patient identifies
problems that threaten abstinence. Problems that are
likely to be mentioned include:
- Negative mood/depression: Provide counseling,
prescribe appropriate medications (eg, bupropion
SR or nortriptyline), or refer the patient to a
specialist.
- Strong/prolonged withdrawal symptoms: Consider
extending the use of an approved pharmacotherapy
or adding/combining pharmacologic medications to
reduce strong withdrawal symptoms.
- Weight gain: Acknowledge that some weight gain
is common after smoking cessation. Emphasize the
importance of physical activity and a healthy diet.
Smokers who are greatly concerned about weight gain
may benefit from bupropion SR or nicotine replacement
therapies (in particular, nicotine gum), both of
which have shown some benefit in delaying postcessation
weight gain.
- Flagging motivation/feeling deprived: Reassure
the patient that such feelings are common. Probe
to learn if the patient has engaged in periodic
tobacco use. Stress that resuming smoking--even
a puff--will increase urges and make quitting more
difficult.
--Stanley Nelson
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Surgeon General's Report
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United
States Surgeon General David Satcher, MD, PhD, believes
that smoking rates can be cut in half by 2010 if antismoking
programs using the approaches summarized in Treating
Tobacco Use and Dependence are fully implemented.
Dr. Satcher made this announcement in Chicago at the
11th World Conference on Tobacco OR Health, where
he released Reducing Tobacco Use,[1] the first
Surgeon General's report to provide an in-depth analysis
of the effectiveness of various methods to reduce
tobacco use. The report recommends that physicians,
public health officials, and legislators:
- Implement
effective school-based programs, combined with community
and media-based activities. Such efforts can prevent
or postpone smoking onset in 20% to 40% of adolescents.
Fewer than 5% of schools nationwide implement the
major components of school guidelines recommended
by the Centers for Disease Control and Prevention.
- Change
physician behavior, medical system procedures, and
insurance coverage to encourage widespread use of
state-of-the-art treatment of nicotine addiction.
The report shows that brief physician advice to
quit smoking can double or quadruple normal quit
rates, while a combination of behavioral counseling
and pharmacologic treatment can boost success as
much as 10-fold.
- Pass
and enforce strong regulations to promote clean
indoor air.
- Improve
tobacco warning labels. The labels used in the United
States are less prominent than those required in
other countries, such as Canada and Australia; US
labels contain very little information regarding
the ingredients, additives, and potential toxicity
of tobacco products.
- Increase
tobacco prices and excise taxes. Evidence presented
in the report suggests that a 10% increase in price
will reduce overall cigarette consumption by 3%
to 5%. However, both the average price of cigarettes
and the average cigarette excise tax in the United
States are well below those in most other industrialized
countries.
--Kristin Della Volpe
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Reference
1. US Department of Health and Human Services. Reducing
Tobacco Use: A Report of the Surgeon General.
Atlanta, Ga: US Department of Health and Human Services,
Centers for Disease Control and Prevention, National
Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health; 2000.
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