Strategies to Assist Patient with Smoking Cessation

by James O’Keefe, Jr, MD (Director of Preventive Medicine, Mid-America Heart Institute, Kansas City, MO), Mark S. Freed, MD (Cardiologist, President of Physicians' Press), and Christie Ballantyne, MD (Clinical Director, Section of Atherosclerosis, Baylor College of Medicine)

Overview

Smoking tobacco is the most preventable cause of death in the United States. Each year, 400,000 deaths are attributable to tobacco use, more than alcohol abuse, automobile accidents, AIDS, homicide, suicide, heroin, and cocaine combined! Compared to age-matched nonsmokers, persons who smoke one pack of cigarettes per day are 14 times as likely to die from cancer of the lung, throat or mouth; four times as likely to die from cancer of the esophagus; and twice as likely to die from heart disease or cancer of the bladder. At any age, the risk of death is doubled in smokers compared with nonsmoking age-matched controls. In addition to the risk of premature death, millions of smokers suffer chronic disability from tobacco-related illnesses, including heart attack, stroke, claudication, and emphysema. Infants of mothers who smoke during and after pregnancy are three times more likely to die from sudden infant death syndrome, and children of smokers have an increased risk of ear infections, pneumonia, bronchitis and tonsillitis, and are more likely to become smokers themselves. Despite these statistics, few physicians routinely ask patients about cigarette smoking or offer counseling about smoking cessation. The risk of coronary artery disease attributable to smoking returns to baseline soon after cessation of tobacco use. By 12-18 months, most of the increase in risk has disappeared; by 3-5 years, the risk of coronary events is no different than that of a nonsmoker. As a physician, there is virtually nothing more effective at improving a patient’s long-term prognosis than convincing and helping him or her to stop smoking. If a physician discusses this topic—even briefly—with the smoker and makes a strong statement about the medical necessity of discontinuing this habit, a person’s chances of permanent cessation of smoking is doubled! The use of bupropion hydrochloride (Zyban) and nicotine replacement therapy (NRT) also increase the chances of successful smoking cessation.

Guidelines

The U. S. Public Health Service recently issued clinical practice guidelines for treating tobacco use and dependence (JAMA 2000;283:3224), recognizing that more than 70% of smokers visit a health care setting each year, and that most smoker want to quit completely. Guidelines were based on 6000 peer-reviewed articles and abstracts, then generated by a panel of 18 members and submitted for external review and revision by more than 70 experts. They concluded that every patient should be asked about cigarette smoking at every visit, that smokers should be strongly encouraged to stop, and that NRT and/or bupropion hydrochloride should be offered to all smokers. In their report, the Expert Panel from the U.S. Public Health Service recommended the following strategies to help patients willing to quit smoking:

Step 1: Systematically identify all tobacco users at every visit.  Place tobacco-use status stickers on all patient charts.

Step 2: Strongly urge all tobacco users to quit.   Advice should be clear, strong, and personalized: "I think it is important for you to quit smoking now, and I can help you." "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." Tie tobacco use to current health/illness, its social and economic costs, motivation level/readiness to quit, and its impact on children and others in the household.

Step 3: Determine willingness to make a quit attempt.   If the patient is willing to make a quit attempt at this time, assist the patient in quitting (Table 1) or refer to a quit-smoking program. If the patient is unwilling to make a quit attempt, provide a motivational intervention.

Step 4: Aid the patient in quitting (Tables 1-2).

Step 5: Schedule follow-up contact.  Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated. Congratulate success during follow-up contact. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Remind patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Consider use or referral to more intensive treatment.

For patients who continue smoking, it is important to appreciate clinically significant interactions between cardiovascular drug therapy and cigarette smoking. These include anticoagulants (increased elimination; may require higher dose of anticoagulant), beta-blockers (increased hepatic metabolism; may require higher dose of beta-blocker), and diuretics (possible increased secretion of vasopressin and decreased diuretic effect).