Smoking cessation: Tactics that make a big difference

,

Applied Evidence

Smoking cessation: Tactics that make a big difference

J Fam Pract. 2007 October;56(10):817-824

By

Agnes O. Coffay, MD

Quitlines, Web support, text messaging, and drugs improve quit rates—if you and your staff set the stage.

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References

1. Brown D. Nicotine up sharply in many cigarettes. Washington Post, August 31, 2006. Available at: www.washingtonpost.com/wp-dyn/content/article/2006/08/30/Ar2006083001418.html. Accessed on September 4, 2007.

2. Agency for Healthcare Research and Quality. Clinical Practice Guideline. Treating Tobacco Use and Dependence. Rockville, Md: US Department of Health and Human Services Public Health Service;2000. Available at: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2. chapter.7644. Accessed on September 4, 2007.

3. Tobacco Use and Dependence clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA. 2000;283:3244-3254.

4. Ask and Act: A Tobacco Cessation Program. Available at: www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html. Accessed on September 4, 2007.

5. Lancaster T, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004;(4):CD000165.-

6. Fiore MC, McCarthy DE, Jackson TC, et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Prev Med 2004;38:412-420.

7. Katz DA, Muehlenbruch DR, Brown RL. Effectiveness of implementing the Agency for Healthcare Research and Quality Smoking cessation clinical Practice Guidelines: a randomized, control trial. J Natl Cancer Inst 2004;96:594-603.

8. Stead LF, Lancaster T, Perera R. Telephone counseling for smoking cessation. Cochrane Database Syst Rev 2003;(1):CD002850.-

9. Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med 2002;347:1087-1093.

10. An LC, Zhu SH, Nelson DB, et al. Benefits of telephone care over primary care for smoking cessation. Arch Intern Med 2006;166:536-542.

11. Etter JF. Comparing the efficacy of two internet-based, computer-tailored smoking cessation programs: a randomized trial. J Med Internet Res 2005;7(1):e2.-

12. Swartz LH, Noell JW, Schroeder SW, Ary DV. A randomized control study of a fully automated internet based smoking cessation programme. Tobacco Control 2006;15:7-12.

13. Rodgers A, Corbett T, Bramley D, et al. Do u smoke after txt? Results of a randomized trial of smoking cessation using mobile phone text messaging. Tobacco Control 2005;14:255-261.

14. Silagy C, Lancaster T, Stead I, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2004;(4):CD000146.-

15. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2004;(2):cD000031.-

16. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997;337:1195-1202.

17. Swan GE, McAfee T, Curry SJ, et al. Effectiveness of bupropion sustained release for smoking cessation in a health care setting. Arch Intern Med 2003;163:2337-2344.

18. da Costa CL, Younes RN, Lourenco MT. A prospective, randomized, double-blind study comparing nortriptyline to placebo. Chest 2002;122:403-408.

19. Hall SM, Reus VI, Munoz RF, et al. Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry 1998;55:683-690.

20. Hall SM, Humfleet GL, Reus VI, et al. Psychological intervention and antidepressant treatment in smoking cessation. Arch Gen Psychiatry 2002;59:930-936.

21. Prochazka AV, Weaver MJ, Keller RT, et al. A randomized trial of nortriptyline for smoking cessation. Arch Intern Med 1998;158:2035-2039.

22. Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database Syst Rev 2004;(3):CD000058.-

23. Hughes JR, Stead LF, Lancaster T. Anxiolytics for smoking cessation. Cochrane Database Syst Rev 2000;(4):CD002849.-

24. Jorenby De, Hays JT, Rigotti NA. Efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA 2006;296:56-63.

25. Gonzales D, Rennard SI, Nides M. Varenicline, an a4b2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation. JAMA 2006;296:47-55.

26. LeHouezec J. Why a nicotine vaccine? Clin Pharmacol Ther 2005;78:453-455.

27. Tuller D. Scientists testing vaccines to help smokers quit. New York Times,July 4, 2006. Available at: www. nytimes.com/2006/07/040health/04vacc.html?ex=13 09665600&en=d978add467c2b80a&ei=5088&partne r=rssnyt&emc=rss. Accessed on September 6, 2007.

28. Fagerström K, Balfour DJ. Neuropharmacology and potential efficacy of new treatments for tobacco dependence. Expert Opin Investig Drugs 2005;15:107-116.

Practice recommendations

Recommend that your patients take advantage of telephone counseling— it improves both quit rates and long-term abstinence rates (A). Web-based cessation programs also help to support smokers in all stages of quitting (B).
Encourage patients to use both pharmacotherapy and counseling to improve abstinence (A). Several medications—including bupropion and varenicline—achieve comparable rates of both quitting and long-term abstinence (A).
Train your office staff to assist in the identification and counseling of smokers (A).

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

Ann G. is a 34-year-old mother of 2 who had been coming to the office for her annual Pap smear for several years. Her medical history is significant only for her vaginal deliveries and mild GERD. Her medications include oral contraceptive pills (OCPs) and over-the-counter Zantac as needed. on her most recent annual visit, my medical assistant, Tammy, took Ann’s vital signs. The chart had a section about smoking status, and Tammy noted that Ann smoked.

During the office visit, I explained to Ann that her smoking was a serious health risk, and that she needed to quit. She would also need to find a new form of birth control next year, as smoking increases the risks of using OCPs. She nervously laughed off the warning.

The following year, Anne confessed to Tammy that she was still a smoker. Tammy asked her again about quitting. Ann was still adamant: “No way—I can’t do it.” Nonetheless, during the office visit, I brought up the subject of her smoking. She admitted that she was afraid that quitting smoking would cause her to gain weight. I attempted to address her fears, and then talked about other birth control methods to consider. I gave her a 3-month prescription of OCPs, and told her in 3 months we would discuss what she wanted to do about birth control.

Ann faces an uphill battle. The amount of nicotine in cigarettes is increasing,¹ making it harder for her to quit. The good news is that the treatment of tobacco addiction is constantly improving and the number of tools in our arsenal is growing. In fact, there are many resources that we can try before turning to the prescription pad. However, when needed, pharmacotherapy is an important adjunct for achieving abstinence.

“5-A” strategy sets stage for success

The Agency for Healthcare Research and Quality (AHRQ) has published Treating Tobacco Use and Dependence, a useful guide for helping patients quit.^2,3 These guidelines discuss many aspects of tobacco cessation, from counseling to pharmacotherapy to reimbursement issues. The guidelines break down the smoking cessation process into the 5 A’s:

Ask each patient about her smoking status.
Advise each patient who smokes that she needs to stop smoking.
Assess your patient’s willingness to make a quit attempt in the next 30 days.
Assist your patient either in making this quit attempt or in motivating her to consider a quit attempt later.
Arrange close follow-up of any quit attempts to help prevent relapse.

The Ask and Act program from the American Academy of Family Physicians (AAFP) outlines a similar strategy.⁴ The program instructs physicians to Ask every patient about her tobacco use and to Act to help her quit, via on-or off-site counseling, quitlines, patient education materials, self-help guides or Web sites, cessation classes, and pharmacotherapy.

Take advantage of every opportunity you have to discuss the issue with patients; short conversations can make a difference. A Cochrane Review of 39 trials including 31,000 smokers⁵ revealed that even brief advice—simply encouraging patients to quit—was statistically significant (odds ratio [OR]=1.74; 95% confidence interval [CI], 1.48–2.05). The pooled data generated a quit rate difference of 2.5%: for every 40 people who were told to quit, 1 more smoker would.

Empower the office staff

Enlisting the help of the office staff can have a significant impact on the health of the patients. A proactive approach was studied by Fiore et al.⁶ Medical assistants, while assessing smoking status, invited all smokers to participate in a cessation study. (The assistants received periodic thank-you gifts for their efforts.)

FAST TRACK

Discuss your patient’s smoking at every opportunity—one study has shown that even brief advice can help

The participants were randomized to either self-selected treatment or nicotine replacement therapy (NRT) patches, with or without a support program. Some who received the patches and support program also received individual counseling. Fiore et al showed that the majority of smokers were open to attempts to quit smoking. The 13% point-prevalence abstinence rate 1 year out is comparable with the rate obtained (14%) with smokers volunteering for NRT studies in the Cochrane review of 39 trials, noted earlier.