Dr. M.J. Bazos,
Patient Handout
Smoking
Cessation
Objectives: Provide a framework for
care providers to assist patients in smoking cessation. Systematic efforts
include the following: 1) Assess and document smoking status of every patient.
2) Provide smoking cessation intervention to all smokers. 3) Treat
behavioral/psychological aspects of cigarette addiction with advice and
counseling. 4) Treat biologic aspects of cigarette addiction with
pharmacological therapies.
Key
Points
_
Assessment. ASK all patients about
smoking status and assess smoker’s readiness to
quit.
Smoking status should be documented
in the medical record.
_
Treatment.
.
ADVISE all smokers to seriously consider making a quit attempt using a
clear and personalized message. Advice as brief as 3 minutes is
effective.
- Offer motivational
intervention to those not yet ready to quit using the 4 “R’s”
- relevance, risks, rewards,
repetition.
. ASSIST those ready
to make a quit attempt:
- Set a quit date.
Quit date abstinence is a strong predictor of long term
success.
- Give advice on quitting and
provide supplementary materials.
- Refer to
more intensified counseling as
appropriate.
- Prescribe pharmacologic
therapy as appropriate. Nicotine replacement therapies and bupropion
hydrochloride have both been proven
effective.
. ARRANGE follow-up
either with phone call or office visit.
-
Prevent relapse by congratulating successes and reinforcing reasons for
quitting.
- Assess any difficulties with
pharmacologic therapy.
Clinical
Problem and Clinical
Dilemma
Smoking-related deaths account
for a fourth of all deaths in this country. Estimated annual cost of
smoking-related medical care was $50 billion in 1993. Approximately 25% of
American men and women continue to smoke. Of these, approximately 70% see a
physician each year. A great majority of smokers report a desire to quit smoking
and cite physician advice as an important motivator for making a quit attempt.
Only about half of smokers report ever having been asked about smoking or
advised to quit. Lack of time, lack of knowledge about counseling and lack of
familiarity with current pharmacologic therapies may all contribute to
inadequate intervention being done by clinicians. It is therefore imperative
that every clinician become comfortable and knowledgeable in an approach to
assist patients with smoking
cessation.
Rationale for
Recommendations
Assessment
All
patients should be asked about their smoking status and assessed for
their willingness to quit. If a patient smokes, this should be documented in the
medical record so that intervention can be offered. Techniques to remind
physician of a patient’s smoking status include smoking status stickers,
listing tobacco use on active problem list or tobacco status as part of vital
signs.
Treatment -
Counseling
Several factors make health
care centers ideal settings for delivery of smoking
cessation
interventions. As stated above,
at least 70% of smokers see a physician each year. As many as 70% of these
smokers report a desire to quit and have made at least one serious quit attempt.
Smokers also report that advice from a clinician is an important motivator to
quit.
Clinician's Actions to Help
Patients Quit Smoking
ASK
every patient about smoking status (Document status in medical
record)
Current smoker? Reinforce
non-use No ADVISE to quit (Message clear, strong, and
personalized)
Yes Ready to
attempt to quit? Patients not ready to quit require motivational intervention.
Review:
•
Relevance
•
Risks
•
Rewards
•
Repetition
1. Set quit
date
2. ASSIST by
providing:
• Personalized
advice
- review prior
attempts
- anticipate
challenges
- prepare
environment
• Pharmacologic
therapy as appropriate
•
Information on community
programs
3. ARRANGE follow-up
(e.g., 1 week and routine clinic visits/ phone
calls)
Abstinent at
follow-up?
Assess reasons for
failure and:
• Consider
referral for more intensive
counseling
• Reassess choice
of pharmacologic
intervention
• Advise to
make another quit attempt
•
Congratulate on success
•
Review /reinforce reasons for
quitting
• If on
pharmacologic therapy, any difficulties? Adjust as
appropriate
Is patient ready
to set quit date?
Counseling
Interventions for Smoking
Cessation
ADVISE: Advise the
patient.
ASSIST: Aid the patient in
quitting.
ARRANGE: Arrange follow-up
at the same visit patient sets quit
date.
Brief clinician
intervention.
Advice should
be:
. Clear - “I think it is
important for you to quit smoking now, and I will help
you.”
. Strong - “As
your clinician, I need you to know that quitting smoking is the most important
thing you can do to protect your current and future
health.”
. Personalized - Tie
smoking to current health/illness, and/or social and economic costs of tobacco,
and/or impact on children or others in household. “The frequency of your
child’s ear infections is certainly related to your smoking
habit.”
1. Help the patient
with a quit plan.
. Set a quit date and
record this on patient’s chart. Ask the patient to mark this on his/her
calendar. Quit date abstinence is a strong predictor of longterm
success.
. Patient should inform family,
friends, co-workers of quit plan and request
support.
. Have patient remove cigarettes
from home, car and workplace
environments.
. Review previous quit
attempts.
. Anticipate challenges,
particularly during the first critical few weeks, i.e., nicotine withdrawal
symptoms.
2. Consider referral to
intensive counseling (multi-session, group or individual).
Referral considerations
include:
. Multiple, unsuccessful quit
attempts initiated by brief intervention.
.
Increased need for skill building (coping strategies/problem solving), social
support and
relapse
prevention.
. Psychiatric co-factor, such
as depression, eating disorder, anxiety disorder, attention deficit disorder, or
alcohol abuse.
3. Encourage
pharmacologic therapies as appropriate.
4. Give key advice on
successful quitting.
. Abstinence.
Total abstinence is essential,
not even a single puff after quit
date.
. Alcohol. Drinking alcohol is
strongly associated with
relapse.
.
Other smokers in the household. The presence of other smokers in the
household, particularly a spouse, is associated with lower success
rates.
Patient should consider quitting with
significant other, or develop specific plan to stay quit in a household where
others still smoke.
5. Provide
supplementary educational materials
.
UMHS patient Education materials:
- "How to
use your nicotine product"
- "Tips for
quitting smoking"
. National Cancer
Institute pamphlet - “Clearing the
Air”
1. Schedule follow-up.
Contact either in person or by telephone. If the patient is scheduled to
return for a clinic appointment,follow-up cessation counseling should be done at
that time. Other follow-up may be done over the
telephone.
2. Timing. Follow-up
contact should occur soon after the quit date, preferably during the
first week . Extending treatment contacts over a number of weeks appears to
increase cessation rates . Further follow-up as
needed.
3. Actions during
follow-up:
. If
abstinent:
. Congratulate success and
stress importance of remaining abstinent.
.
Review benefits to be derived from
quitting.
. Inquire regarding problems
encountered and offer possible solutions to maintaining
abstinence.
. If
smoking:
. Review circumstances and
elicit re-commitment to total abstinence.
.
Remind patients that a lapse can be used as a learning
experience.
. Identify problems, suggest
alternative behaviors and anticipate challenges in the immediate
future.
. Re-assess choice of pharmacologic
intervention as needed.
. Consider referral
to a more intense or specialized program.
Dosing and Administration Of
Nicotine Replacement Therapy and
Bupropion
Agent
Available
Dosages/Cost
Dosing
Duration Instructions Side
Effects
Transdermal
nicotine patch
Continuous
delivery of nicotine provides constant blood levels. Requires 2-3 days to
achieve maximal
serum
levels.
Over-the-Counter
Nicoderm
CQ 21, 14, 7 mg/ 24 hr All: $27 /
7
Nicotrol 15mg/16 hr $27 /
7
Other Generic Nicotine
Transdermal Patches 7, 14, 21 mg - $27 / 7 >10 cigs per day, start with
highest dose of given brand. 5 - 10 cigs per day, use mid-range dose 8 weeks. No
increase in cessation with longer duration
Suggest:
.
Weeks 1-4: highest dose of given
brand
. Weeks 4-6: next lowest
dose of brand
. Weeks 6-8: lowest
dose Taper recommended for psychological reasons, but does not increase efficacy
. No smoking while on patch, rotate to new hairless skin site each day,
remove before bed if insomnia. May consider supplement with 2 mg gum first 48
hrs while plasma levels building Skin reactions including pruritus, edema, rash;
sleep
disturbance.
Nicotine
Gum
(polacrilex):
Maximum
nicotine levels achieved within 20-30 minutes of
chewing.
Over-the-Counter
Nicorette
- 2 and 4 mg sticks
2 mg - $47 /
108 pack
4 mg - $53 / 108
pack
Generic nicotine: polacrilex
(Watson)
2 mg - $40 /
108
4 mg - $45 /
108
> 20 cigs per day, use 4 mg
stick q one hour
< 20 cigs per
day, use
2 mg stick q one
hour.
2-3 months . Chew until
spicy flavor begins, then “park” between cheek and gum for
absorption. Remove after ½ hour. Acidic beverages decrease absorption. Jaw
fatigue, hiccups, belching, nausea.
Nicotine Nasal
Spray
Maximum levels of
nicotine reached within 5 - 10 minutes. Levels begin to fall within 30 minutes
of dose. Most closely mimics nicotine delivery pattern of
cigarette.
Prescription
Nicotrol
NS
1 mg = 1 spray each nostril = 1
dose
1-10 ml spray -
$43
Spray q 30-60 minutes prn
craving.
Maximum 40 doses/day; 2-3
months
Careful instruction on
spray technique (see patient education
handout).
Nasal irritation /
rhinorrhea (98% of pts), sneeze,
cough.
Decreased severity of
effects after first
week.
Nicotine
Inhaler
Nicotine absorbed
through mouth and throat (not lungs) when smoker “puffs” on cylinder
delivering nicotine and menthol. Peak nicotine levels in 20
minutes.
Prescription
Each
inhaler cartridge with 10 mg nicotine
Nicotrol inhaler: 42 cartridge /
1 mouthpiece - $43
80 puffs
=1mg
Requires 3-4 puffs /minute
for 20-30 minutes. Use prn or q 1 hour. Each cartridge good for approx. 20
minutes of continuous puffing. 2-3 months [D*]. Must puff more frequently
than cigarettes. Cough, mouth and throat
irritation.
Bupropion
hydrochloride
SR
(Zyban®)
Prescription
150
mg SR tablets
$22/week or $157/7
weeks at BID dose; 150 mg/day for 3 days, then 150 mg
BID
7 weeks Start 1 week before
quit date Insomnia and dry
mouth.
Contraindications:
Seizure
disorder, major head trauma, eating disorder, or on Wellbutrin® or MAO
inhibitors. January 2001 Average wholesale price (AWP) drug costs rounded to the
nearest dollar.
"4 R’s" of
Motivational Intervention For Patients Not Yet Ready to Make a Quit Attempt
Relevance
Tie smoking to current
health/illness, and/or social and economic costs of tobacco use, motivation
level/readiness to quit, and/or the impact of smoking on children and others in
the household. For example, “Your child's asthma flare is certainly
related to your smoking habit. It would be in your child’s best interest
for you to set a quit date in the near
future.”
Risks
Ask
patient to identify potential negative consequences of
smoking:
. Acute risks - shortness of
breath, exacerbation of asthma, impotence,
infertility
. Long term risks - heart
attacks, strokes, lung and other cancers,
COPD
. Environmental risks - increased risk
of lung cancer in spouse and children; higher
rates
of smoking by children; increased
risk for SIDS, asthma, middle ear disease and respiratory infection in
children
Rewards
Ask
patient to identify:
1) any positive
benefits they currently derive from smoking. Discuss alternative methods for
filling the potential void after cessation.
2) the potential rewards of smoking
cessation including improved health, improved taste, money saved, healthier
children, freedom from
addiction.
Repetition
Repeat
above strategies every time an unmotivated patient has a
visit.
Treatment - Counseling
(continued)
The brief clinic
intervention is known as the “4-A” model: Ask, Advise,
Assist, Arrange. Asking is the key component of the initial
assessment and encourages consistent and accurate identification of all smokers.
Once it is established that a patient smokes, clinician advice as brief
as 3 minutes is effective in smoking cessation . The physician then assesses
patient readiness to quit. Assisting with the actual quit plan and
Arranging follow-up contact then ensue for those patients ready to quit.
Specific counseling techniques under the 4-A plan. Results of the Public Health
Service guideline panel metaanalysis showed that brief intervention increases
long-term quit rates. In addition, there is a strong dose response relationship
between the intensity of person-to-person contact and successful outcomes . When
providing counseling, health care providers should be aware that barriers to
smoking cessation include, but are not limited to, severe withdrawal during
previous quit attempts, the presence of other smokers in the home or workplace,
stressful life circumstances, psychiatric co-morbidities (i.e. depression,
alcoholism), and low motivation. Identifying these barriers during initial
assessment will help to provide a tailored approach during counseling. In
addition to clinician counseling in the office, intensive counseling (frequently
defined as a minimum of weekly meetings for the first 4 - 7 weeks of cessation)
significantly enhances cessation rates. However, participation in intensive
counseling is based largely on patients’ motivation to quit and ability to
pay . Typically, only a minority of smokers are willing to quit at any point in
time, and many clinicians will spend more time promoting the motivation to quit
than assisting in quit attempts.
Treatment - Pharmacologic
Therapies
Both nicotine replacement
therapy (NRT) and bupropion hydrochloride (Zyban®) have been shown to
significantly improve cessation rates
.
Therefore, pharmacologic therapy should be
recommended to all patients except in the presence of special circumstances (see
Special Populations). To date, bupropion hydrochloride is the only non-nicotine
product with FDA approval for smoking cessation. Non-FDA approved agents with
potential benefit in smoking cessation include nortriptyline and clonidine. The
following sections discuss choosing among the various forms of NRT, bupropion,
and other agents.
Nicotine
replacement therapies (NRT). NRT has been used for many years, but
alternative methods of delivery continue to be developed and new combinations
are being tried. Pharmacologic properties of nicotine: A smoker absorbs
1-3 mg of nicotine per cigarette regardless of nicotine-yield ratings on the
box. Nicotine results in increased release of catecholamines, vasopressin,
6 UMHS Smoking Cessation Guideline,
February 2001 endorphins, cortisol and ACTH.
These biochemical changes lead to addiction as smokers experience pleasure,
increased arousal, decreased anxiety, and decreased hunger with increased
metabolic rate. Within hours of cessation of cigarettes, smokers begin to
experience the nicotine withdrawal syndrome that peaks at 48 hours. Symptoms of
nicotine withdrawal include: craving, anxiety, restlessness, irritability,
depressed mood, increased appetite
and
difficulty concentrating.
Demonstration of efficacy: The various nicotine replacement therapies
(NRT) significantly decrease symptoms of the withdrawal syndrome as smokers
abruptly stop smoking . The different formulations of NRT provide alternate
methods for delivery and have slightly different onset of action and duration.
In meta-analyses, cessation rates with transdermal nicotine range from 15-31 per
hundred with a trend toward decreased efficacy in the most highly dependent
smokers (≥ 32 cigarettes / day or Fagerstrom nicotine dependence score
> 6) .
Nicotine gum studies demonstrate a similar
range of cessation rates with greatest efficacy seen with the 4mg gum in highly
dependent smokers .
Nasal spray cessation rates range from
26-28 per hundred, also with greatest efficacy in the most dependent smokers
.
Inhaler studies report cessation rates
similar to that of the nasal
spray.
Only the patch has proven efficacy with
minimal counseling, although efficacy is improved with intensive counseling. All
nasal spray and inhaler studies have been performed with concomitant intensive
counseling. Level of dependence and dosing: In very highly dependent
smokers, 4 mg gum is superior to 2 mg and most effective with counseling. High
dose patch therapy (i.e,. 44 mg/24hr = two patches) is safe and decreases
withdrawal symptoms in highly dependent smokers, but does not increase long term
cessation rates. Those smoking 5 or fewer cigarettes per day have been shown to
have few symptoms of nicotine withdrawal when they
quit
and may not require nicotine replacement
therapy.
For those using nicotine gum, spray or
inhaler, it is important that they are instructed in technique and dosing
frequency so that underdosing does not occur. See Table 2 for dosing and
administration recommendations. You may also provide the patient with the
attached educational handout, “How to Use Your Nicotine Product”.
Choosing among various nicotine
replacement therapies: A single randomized study comparing the 4
nicotine replacement therapies showed similar abstinence rates at 12 weeks
despite the fact that the nasal spray and inhaler groups had lower compliance
with prescribed methods of use. Therefore, choice of NRT may be tailored to
patients’ preferences, side effects and previous attempts. The transdermal
patch offers convenience, minimal instruction and minimal side effects. The
continuous transdermal release of nicotine from the patch does not produce the
peaks and troughs that are similar to cigarette smoking. Alternatively, gum,
spray or inhaler therapy may allow for a “quick fix” when cravings
occur; this more closely simulates the nicotine peaks of actual cigarette
smoking. (It is of note that the reinforcing effects of a bolus of nicotine have
been suggested to contribute to the habitual effects of nicotine. Eight to 25%
of gum users, 10-
43% of spray users, and
16% of inhaler users who quit smoking were still using the nicotine replacement
therapy beyond 6 months ) Combining nicotine replacement therapies. At least 3
randomized, controlled trials have now examined the efficacy of combining either
patch plus gum, patch plus inhaler or patch plus nasal spray. While all show
significantly improved early (6 week) abstinence rates, only the patch plus
spray showed improved effectiveness over the patch alone at one year (27 per 100
versus 11 per 100.) One-third of those abstainers at one year were still using
the nasal spray.
Given the additional cost of dual
therapies and limited benefit, this approach is best reserved for highly
addicted smokers with several previous failed quit
attempts.
Patients with cardiovascular
disease: The patch and nasal spray have demonstrated safety in patients with
stable coronary artery disease. These agents have not been evaluated in
patients with unstable angina, recent myocardial infarction, uncontrolled
congestive heart failure or unstable arrhythmia. While patients should be
reminded not to smoke while using these products, studies have shown no increase
in cardiac event rates when patients smoke while wearing the patch. Nicotine gum
and inhaler have not been specifically studied in this
population.
Bupropion hydrochloride
(Zyban_,
Wellbutrin_).
Bupropion was
initially developed and marketed as an antidepressant medication (Wellbutrin_).
The mechanism by which bupropion aids smoking cessation is unknown, but is
believed to effect central dopaminergic and noradrenergic pathways involved in
nicotine addiction and withdrawal. In the single placebo-controlled trial
published to date, cessation rates at one year were 23 per hundred smokers.
Dosing and administration: The manufacturer recommends initiation of drug
therapy 1 week prior to quit date. The recommended dosage schedule includes a
starting dose of 150 mg per day for three days, then increasing to twice per
day. However, initial studies revealed no significant differences in smoking
cessation among patients receiving total daily doses of 150 or 300 mg at 6 or 12
months. Therefore, patients who cannot afford or tolerate 300 mg/day may achieve
successful results on 150 mg/day. The appropriate total duration of bupropion
has not been studied. In the single published study, smokers took bupropion for
7 weeks. The cost of one month of Zyban_ therapy is approximately $118 (January
2001 Average Wholesale Price rounded to the nearest dollar).
Contraindications: Bupropion hydrochloride (Zyban_) is contraindicated in
patients with seizure disorder, past or present eating disorder, and in patients
being treated with Wellbutrin_ or MAO inhibitors. To reduce seizure risk, the
manufacturer recommends not exceeding maximum
7 UMHS Smoking Cessation Guideline,
February 2001 daily dose of 300 mg or single
dose of 150 mg. Doses should be taken at least 8 hours apart. It should be used
with caution in patients with predisposition to seizure (i.e., head trauma,
alcohol withdrawal, concomitant use with other medications that lower seizure
threshold - antipsychotics, antidepressants,
theophylline.)
Choosing between
bupropion hydrochloride or nicotine replacement.
A single trial sponsored by the
manufacturer of Zyban, compared bupropion, bupropion/nicotine patch combination,
nicotine patch and placebo. At 1 year, bupropion and combination therapy had
higher rates of smoking cessation than either the patch alone or placebo. (30
per hundred smokers with bupropion; 16 per hundred smokers with the nicotine
patch.) There was no significant benefit of combination therapy over bupropion
alone. The study suffered from an intervention discontinuation rate of 35%. This
single study suggests that bupropion may be superior to nicotine patch
therapy.
No conclusions may be drawn about the
superiority of bupropion over other nicotine products. Given this single study,
it remains reasonable to consider patient preferences, previous quit attempt
experiences and cost when choosing among pharmacologic
therapies.
Other
pharmacologic therapies.
A
meta-analysis of 6 placebo-controlled trials of clonidine revealed a pooled odds
ratio for benefit over placebo of 1.89.(CI 1.30-2.74) In only one of the 6
trials did clonidine show a statistically significant effect. Dry mouth and
sedation were common side effects. A single placebo-controlled study of
nortriptyline has shown 6 month cessation rates of 14 per hundred with use of
nortriptyline at a targeted dose of 75mg. (Dose achieved by 85% of subjects.)
Sixty-four percent of subjects using nortriptyline complained of dry mouth. To
date, neither drug has FDA approval as an aid in smoking cessation. Given the
single nortriptyline study and marginal effectiveness of clonidine, these drugs
may best be used as second-line agents when patients cannot take or do not wish
to take either NRT or
bupropion.
Effect
of smoking cessation on other
drugs.
Properties of smoke other than
nicotine (benzopyrenes) increase metabolism of other drugs. In particular,
theophylline halflife will increase within one week after smoking cessation. In
addition, plasma caffeine concentrations increase greatly with cessation.
Patients should be made aware that baseline caffeine intake may have greater
physiologic effect and may be misinterpreted as nicotine
withdrawal.
Weight
Gain
Most smokers who quit will gain
weight, but the majority will gain less than 10
pounds.
The physician should acknowledge this and
encourage patients to adopt a healthy lifestyle that includes moderate exercise
and healthy diet. However, very restrictive dieting at the same time may be
counterproductive. A reminder to the patient to work on one issue at a
time and that you will assist the patient with any weight gain issues as needed
may be helpful. Although bupropion hydrochloride at a dose of 300mg/day
had a lower percentage weight gain after 7 weeks of therapy as compared to
placebo, this effect was not sustained at 6 months and therefore is not likely
to be any better than NRT for prevention of post-cessation weight gain.
Nicotine gum may delay post-cessation weight gain, but the weight is usually
gained once gum use
ceases.
Special
Populations
Pregnant patients.
Intensive counseling interventions
increase quit rates during
pregnancy.
If intensive counseling is not possible,
brief in-office counseling still has a beneficial effect and should be offered.
No studies have addressed the safety of nicotine replacement therapy or
bupropion hydrochloride in pregnancy. FDA pregnancy risk categories are:
Zyban® - category B, nicotine transdermal, spray and inhaler - category D,
nicotine gum - category
C.
Adolescents.
The above treatment strategies will
apply to most adolescents who smoke. Clinicians should personalize the encounter
to the individual adolescent’s situation. Nicotine replacement therapy may
be considered. Bupropion has been studied only in
adults.
Racial and Ethnic
Minorities.
Smoking cessation
treatment has been shown to be effective across both racial and ethnic
minorities.
Little research has examined intervention
specifically designed for a particular ethnic or racial group; however, it is
recommended that, when possible, smoking cessation treatment should be tailored
to the specific ethnic or racial population with which they are
used.
It is essential that counseling or
self-help materials be conveyed in a language understood by the
smoker.
Psychiatric co-factors.
If presence of psychiatric cofactors,
such as depression, eating disorder, anxiety disorder, attention deficit
disorder, or alcohol abuse, strongly consider referral to intensive counseling.
Treatment of co-factors must be undertaken in preparation for smoking
cessation.
Non-cigarette tobacco
users.
Spit tobacco users should be
identified and strongly urged to quit tobacco use, using the same counseling
interventions recommended for
smokers.
The clinicians should provide a clear
message that the use of spit tobacco is not a safe alternative to smoking.
However, several studies have found that use of nicotine gum and nicotine patch
have not increased the abstinence rates in spit tobacco users. Users of cigars,
pipes, and other non-cigarette combustible forms of tobacco should be
identified, strongly urged to quit, and offered the same counseling
interventions recommended for
smokers.
Gender
concerns.
Smoking cessation treatments
are shown to benefit both women and
men.
Two studies
8 UMHS Smoking Cessation Guideline,
February 2001 suggest that some treatments are
less efficacious in women than in men. Women may face different stressors and
barriers to quitting (e.g., greater likelihood of depression, greater weight
control concerns, and hormonal cycles). This research suggests cessation
programs that address these issues would be more effective in treating women.
Few studies have examined programs targeted to one
gender.
Older
Smokers.
Smoking cessation treatments
have been shown to be effective for older adults and should be
provided.
Smokers over the age of 65 can both quit
and benefit from abstinence. Due to particular concerns of this population
(e.g., mobility issues) the use of proactive telephone counseling appears to be
promising as a treatment
modality.
Hospitalized Smokers.
A few studies comparing augmented
smoking cessation with usual care of hospitalized patients suggest smoking
cessation treatment to be effective. Additional treatment included self-help
brochures or audio/video tapes, chart prompts reminding physicians to advise for
cessation, pharmacological therapy, hospital counseling, and post-discharge
counseling telephone calls. Hospitalization should be used as a springboard to
promote smoking
cessation.
Controversial
Areas
Other cessation aids.
There is currently insufficient
evidence to recommend the use of additional modalities such as hypnosis or laser
as aids to smoking cessation. A meta-analysis of trials of acupuncture for
smoking cessation failed to show any benefit over sham acupuncture at 12
months.
Information
the Patient Needs to
Know
Supplementary Information
Materials
The UMHS produces two useful
patient education handouts:
. "How to use
your nicotine product"
. "Tips for quitting
smoking"
Additionally, the National Cancer
institute produces the pamphlet, "Clearing the air" (NIH Pub. 94-1647). You may
obtain 20 free copies at a time by calling 1 800-4-CANCER
(1-800-422-6237).
Preparation and
Effects
Review with patients the
following additional information about preparing for quitting and related
factors.
. Review handout(s).
The handout(s) provide many useful tips to
help you with your quit attempt. Read these and make plans before your quit
attempt.
. NRT - if applicable.
Nicotine replacement therapies are
most effective when used correctly. If you have any uncertainties about proper
use, this should be clarified.
.
Caffeine.
You are likely to
perceive greater effects from your usual caffeine consumption after you quit
smoking and may need to decrease your
intake.
. Theophylline.
If you take theophylline, levels should be
checked approximately 2 weeks after you quit
smoking.
Organizing a Health Care Site
to Support Smoking Cessation
Efforts
Successful intervention
programs require coordinated efforts at a health care site. Several clinic
personnel may be involved in the operational steps of “Asking, Advising,
Assisting, and Arranging”. Clinicians should help their clinics develop a
coordinated plan of tasks and who will perform them. Some specific areas for
planning include:
. Record smoking
status. Institute an office system to identify all
smokers:
. Identify where smoking status
will be recorded. Options include making smoking status part of vital signs,
placing smoking status stickers on charts, or including smoking status on a
section of the Problem Summary List.
.
Determine who will routinely ask and record the
information.
. Instruct staff regarding
their roles in documentation.
. Reinforce
the value of the documentation.
.
Smoking cessation follow-up.
Develop a system and assigned role(s)
at the health care site to:
. Ensure the
availability of patient education materials on smoking
cessation.
. Establish procedures for
clinicians to provide a designated follow-up person with information on patients
who are setting quit dates. Coordinate follow-up phone calls in conjunction with
quit dates.
. Provide follow-up cessation
counseling as needed at subsequent clinic
visits.
. Refer patients to more intensive
counseling programs for smoking cessation, as
needed.
References
Clinical
Practice Guideline: Treating Tobacco Use and Dependence. Washington,
D.C.: US Public Health Service, 2000, Gov. Publication No. AHRZ 00-0032
(Internet:
http://www.surgeongeneral.gov/tobacco/smokesum.htm)
This
108 page guideline is an updated version of the 1996 Smoking Cessation Clinical
Practice sponsored by the Agency for Health Care Policy and Research (now the
Agency for Healthcare Research and Quality [AHRQ]), U.S. Department of Health
and Human Services. The original guideline reflected the extant scientific
research literature published between 1975 and 1994. The updated guideline adds
literature published between 1995 and 1998. Findings include: multiple
efficacious treatments exist, these treatments can double or triple the
likelihood of longterm cessation, many cessation treatments are appropriate for
primary care settings, and the use and impact of cessation treatments can be
increased by supportive health system policies. Sections address screening and
assessment, treatment structure and intensity, treatment elements, and special
populations and special topics. This
is the
single most comprehensive practical reference currently available on the topic
of smoking cessation.