21: Tobacco Use

Cigarette smoking is the leading preventable cause of death in the United States, responsible for an estimated 443,000 deaths per year, or one in every five deaths. Physicians often care for the health consequences of their patients’ tobacco use, and it is equally important for them to prevent smoking-related disease. There is no safe level of tobacco use. Smoking as few as one to four cigarettes per day increases the risk of myocardial infarction and cardiovascular mortality. Smoking cigarettes with reduced tar and nicotine content does not protect against the health hazards of smoking. Smoking cessation treatment is one of the most cost-effective actions available to clinicians.

The prevalence of cigarette smoking in the United States rose rapidly in the first half of the twentieth century and peaked in 1965, when 40% of adult Americans smoked cigarettes. Since then, smoking prevalence has been cut in half, reaching 19% of adults in 2011. This dramatic decline reflects growing public awareness of the health risks of tobacco and decades of public health efforts to discourage tobacco use. More recently, smoking prevalence has stabilized but the pattern of tobacco use has changed. Twenty percent of current smokers do not smoke every day, and the average smoker smokes only 15 cigarettes daily. Combining cigarette smoking with other tobacco products, especially smokeless tobacco, is increasingly reflecting the impact of expanding restrictions on places where smoking is allowed. The rising cost of cigarettes has led increasing number of smokers to use small cigars that have lower tobacco excise taxes and to buy tobacco in bulk and roll their own cigarettes.

Tobacco smoking starts during childhood and adolescence. Nearly 90% of smokers begin to smoke before the age of 18 years and 99% start by the age of 26 years. The rates of tobacco use in men and women, once very different, are now similar, with 16.5% of adult women and 21.6% of adult men smoking cigarettes in 2011. In the United States, smoking is more closely linked to education than it is to age, race, occupation, or any other sociodemographic factors. Educational attainment is a marker for socioeconomic status, and these data indicate that smoking is a problem that is concentrated in lower socioeconomic groups. Smoking is also more prevalent among individuals with comorbid psychiatric disorders and substance abuse disorders.

Cigarette smoking increases overall mortality and morbidity rates and is a cause of cardiovascular disease (including myocardial infarction and sudden death), cerebrovascular disease; peripheral vascular disease; chronic obstructive pulmonary disease; and cancers at many sites, including the lung, larynx, oral cavity, esophagus, bladder, kidney, pancreas, and uterine cervix. Approximately 30% of tobacco-related deaths are due to cardiovascular disease. Lung cancer, once a rare disease, increased dramatically during the twentieth century, becoming the leading cause of deaths due to cancer among men in 1955 and among women in 1986. Lung cancer incidence is now declining among both men and women, reflecting the decline in smoking prevalence by US adults that occurred decades earlier.

Smoking is associated with many pregnancy complications, especially low birth weight (<2500 g). This is primarily attributable to intrauterine growth retardation (IUGR), although smoking in pregnancy also increases the risk of preterm delivery. Other adverse pregnancy outcomes linked to smoking are miscarriage (spontaneous abortion) and stillbirth. Smoking during pregnancy affects children even after birth. Sudden infant death syndrome is two to four times more common in infants born to mothers who smoked during pregnancy. Cognitive deficits and developmental problems in childhood are also linked to maternal smoking during pregnancy.

Cigarette smoking also increases a woman’s risk of postmenopausal osteoporosis and fracture. Smokers have higher rates of upper and lower respiratory infections, diabetes, peptic ulcer disease, cataracts, macular degeneration, and sensorineural hearing loss than nonsmokers. Smokers have more prominent skin wrinkling than nonsmokers, independent of sun exposure. Smoking causes the majority of residential fire deaths.

The health hazards of smoking are not limited to those who smoke. Nonsmokers are harmed by exposure to the smoke produced by nearby smokers, a phenomenon called secondhand smoke (SHS). According to the 2006 US Surgeon General’s Report, there is no safe level of exposure to SHS. The children of parents who smoke have more serious respiratory infections during infancy and childhood, more respiratory symptoms, and a higher rate of chronic otitis media and asthma than the children of nonsmokers. Among adults, chronic SHS exposure increases a nonsmoker’s risk of lung cancer and coronary heart disease. An estimated 3400 lung cancer deaths and 69,000 heart disease deaths in US nonsmokers are attributable to SHS exposure. Even after tobacco smoke has dissipated it leaves a residual of chemicals on clothing and surfaces in the area where tobacco was smoked. This phenomenon, called thirdhand smoke, allows for even more prolonged exposure to tobacco toxins.

Smoking cessation has health benefits for men and women of all ages, even for those who stop smoking after the age of 65 years or who quit after the development of a smoking-related disease. Smoking cessation decreases the risk of lung and other cancers, heart attack, stroke, chronic lung disease, and peptic ulcer disease. After 10–15 years of abstinence, overall mortality rates for smokers approach rates of those who never smoked. The risk reduction for cardiovascular disease occurs more rapidly than the risk reduction for lung cancer or overall mortality. Half of the excess risk of cardiovascular mortality is eliminated in the first year of quitting, whereas for lung cancer, 30–50% of the excess risk is still evident 10 years after quitting and some excess risk remains after 15 years.

The benefits of stopping smoking translate into a longer life expectancy for former smokers compared with continuing smokers. Smokers who benefit the most are those who quit when they are younger, have fewer pack-years of tobacco exposure, and are free of smoking-related disease. The health benefits of smoking cessation far exceed any risks from the small weight gain that occurs with cessation.

Cigarettes and other tobacco products are addictive because they contain nicotine, a drug that creates tolerance and physical dependence in habitual users with symptoms of nicotine withdrawal when smoking stops. Nicotine withdrawal symptoms include: (1) cravings for a cigarette; (2) irritability; (3) restlessness; (4) anger and impatience; (5) difficulty concentrating; (6) anxiety; (7) depressed mood; (8) excessive hunger; and (9) sleep disturbance. These symptoms begin within a few hours of the last cigarette, are strongest during the first 2–3 days after quitting, and gradually diminish over a month or more. Other than craving for a cigarette, the symptoms are nonspecific, and many smokers fail to recognize them as nicotine withdrawal. The severity of nicotine withdrawal is variable across smokers and is related to the level of prior nicotine intake. Smokers who smoke more than 20 cigarettes daily or smoke their first cigarette within 30 minutes of awakening are likely to suffer from nicotine withdrawal symptoms when they try to quit.

The discomfort of nicotine withdrawal is one reason smokers fail in their efforts to stop. However, the attractiveness of smoking is attributable to more than nicotine dependence. Smoking is also a habit, a behavior that has become an integral part of a daily routine. Smokers come to associate cigarettes with enjoyable activities, such as finishing a meal or having a cup of coffee. These actions trigger the desire for a cigarette in smokers who are trying to quit. Smokers also use cigarettes to cope with stress and negative emotions, such as anger, anxiety, loneliness, or frustration. Quitting smoking represents the loss of a valuable coping tool for many smokers.

Over half of the living Americans who have ever smoked have now quit smoking. According to surveys, 70% of the remaining smokers would like to stop smoking and half of them tried to do so in the past year. However, most quit attempts fail, in part because only one in three smokers trying to quit use any assistance when quitting, despite the existence of effective treatments that improve the success rate of a quit attempt.

Approximately 25% of smokers who use state-of-the-art treatment are not smoking 1 year after their quit attempt, though many more smokers quit for a short time and then relapse. Most relapse occurs in the first week of a quit attempt. In contrast, only 6% of smokers who try to quit without assistance succeed for 1 year. Behavioral scientists regard smoking cessation to be a learning process rather than an action requiring a discrete episode of will power. Smokers learn from mistakes made during a prior attempt at quitting, thereby increasing the likelihood that the next attempt will succeed. Psychologists have identified a series of cognitive stages through which smokers pass as they move toward nonsmoking: (1) initial disinterest in quitting; (2) thinking about health risks and contemplating quitting; (3) preparing to quit in the near future; (4) currently taking action to stop smoking; and (5) maintained nonsmoking (see Chapter 19).

Surveys of former smokers reveal how and why they stop smoking. Fear of illness is the reason most often cited. However, awareness of health risks alone is not sufficient to motivate smoking cessation. Over 90% of current smokers know that smoking is harmful to their health, yet they continue to smoke. Many smokers rationalize that they are immune to the health risks of smoking until these risks become personally salient. Current symptoms (e.g., cough, breathlessness, and chest pain), even if they represent minor illness rather than the onset of a smoking-related disease, stimulate change in smoking behavior more powerfully than does fear of future disease. Illness in a family member may also motivate smoking cessation. The price of cigarettes and the social unacceptability of smoking are other frequently cited reasons.

Evidence-based clinical guidelines for smoking cessation were released by the US Public Health Service in 2000 and updated in 2008 (http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf). These guidelines identify two methods, psychosocial counseling and pharmacotherapy, as having strong evidence of efficacy. Each is effective individually, but combining the two produces higher cessation rates. There is no strong evidence to support the efficacy of hypnosis or acupuncture for smoking cessation.

Psychosocial Support

Effective psychosocial support provides smokers with both practical behavior change strategies and also support and encouragement as part of treatment. Cognitive behavioral treatment methods address the barriers to quitting smoking that are rooted in habit. These methods are effective in aiding smoking cessation. In a typical program, smokers monitor their cigarette intake to identify the things that trigger the smoking, change their habits to break the link between the trigger and smoking, and learn to anticipate and handle the urges to smoke when they occur. The counselor also provides social support to bolster the smoker’s confidence in the ability to stop smoking.

Psychosocial support was originally developed for delivery in individual or group settings. To broaden the reach of behavioral treatment, in-person methods were adapted for delivery by telephone and found to be effective. Cognitive behavioral treatment techniques can also be packaged into booklets or videotapes for use at home. These techniques have also been adapted for delivery using newer communication tools, including websites, text messaging, mobile phone applications, and social media. Most of these programs are new and their effectiveness is not yet demonstrated.

Pharmacological Treatment

Seven products have been approved by the US Food and Drug Administration (FDA) as smoking cessation aids and rated as first-line drugs by the US Public Health Service tobacco treatment guidelines (Table 21-1). These include five nicotine replacement products, bupropion (an atypical antidepressant), and varenicline, a nicotine receptor partial agonist. Nortriptyline and clonidine have also shown efficacy for smoking cessation in clinical trials but have not been submitted for approval by the FDA for this indication and are considered second-line drugs by the US Public Health Service guideline panel.

Nicotine Replacement Therapy

The rationale of nicotine replacement therapy (NRT) is to supply nicotine in a form other than a cigarette to block the symptoms of nicotine withdrawal. Nicotine replacement permits the smoker to break the smoking habit first and begin to taper off nicotine. Five forms of nicotine replacement are approved for use in the United States. Nicotine in the form of a gum, a transdermal skin patch, and an oral lozenge are sold without prescription. A nicotine nasal spray and an oral inhaler are prescription-only products. Of all these products, the nicotine patch produces the most constant blood level of nicotine, a substantially different pattern from the fluctuating nicotine levels produced by cigarette smoking. The gum, lozenge, inhaler, and nasal spray produce nicotine levels that vary more than the patch but less than smoking a cigarette. They provide more control over nicotine level. The nicotine supplied by the gum, patch, or nasal spray is sufficient to reduce nicotine withdrawal symptoms, but does not reproduce the rapid rise in nicotine blood levels that results from smoking a cigarette.

Randomized, placebo-controlled trials demonstrate that nicotine gum, patch, lozenge, inhaler, and nasal spray all reduce symptoms of nicotine withdrawal at approximately double the rates of smoking cessation compared with placebo. Combining the patch with another NRT product is safe and more effective than using a single NRT product. The effectiveness of all products depends on the instruction and counseling that accompany it. This is particularly true for the gum, nasal spray, and inhaler, which require careful instruction for proper use. Adherence is less of a problem with the nicotine patch. Any NRT product is more effective if used with some behavioral smoking cessation support. Clinicians should refer smokers to these resources when they recommend or prescribe NRT products.

Nicotine replacement is safe to use in smokers with stable coronary artery disease. There are no data on its safety for use in smokers with unstable cardiovascular disease (myocardial infarction in the past 2 weeks, unstable angina, or life-threatening ventricular arrhythmias), although it is clearly safer than continuing to smoke. Nicotine does increase heart rate and blood pressure, causes vasoconstriction, and is thrombogenic. However, a smoker who substitutes NRT for cigarettes avoids exposure to carbon monoxide and to oxidant gases generated by burning tobacco.

Transdermal Nicotine Patch

The nonprescription nicotine patch contains a reservoir of nicotine that is released at a fixed dose and is absorbed through the skin. On the morning of the quit day, the smoker applies the first patch and removes it 24 hours later. A new patch is applied to rotating skin sites each morning afterward for 2–3 months, although there is evidence that prolonging use beyond 3 months produces better long-term results. Smokers who smoke 10 or more cigarettes (half of a pack) daily start with the 21-mg patch; lighter smokers start with the 14-mg patch. After 4–6 weeks, the smokers progressively switch to a lower dose patch. The most common side effect is local skin irritation, which rarely requires discontinuation of treatment and can often be managed with topical steroids. Vivid dreams or insomnia can be managed by removing the patch at bedtime. Long-term dependence on the nicotine patch rarely occurs.

Nicotine Gum

Nicotine gum is available without prescription in 2-mg and 4-mg strengths and in several flavors. Smokers who smoke more than 25 cigarettes daily use the 4-mg gum; all others use the 2-mg gum. Proper chewing technique is essential for the nicotine released by chewing to be absorbed through the oral mucosa as intended, rather than being swallowed. The gum should not be chewed like regular gum. Initially, it should be chewed only long enough to release the nicotine, producing a peppery taste, and then placed between the gums and buccal mucosa to allow for nicotine absorption. When the taste disappears, the gum is chewed again until the taste reappears, then “parked” again. After 30 minutes, it is discarded. The smoker should not eat or drink while the gum is in the mouth, and should avoid beverages, especially acidic beverages (e.g., coffee) for 30 minutes of gum use. Common side effects include those related to nicotine (nausea, dyspepsia, hiccups, dizziness) and to chewing (sore jaw, mouth ulcers). The product is approved for use as needed to handle urges to smoke, but its onset of action is slower than smoking. Most patients chew fewer than the recommended 9–12 pieces daily. Consequently, many experts use fixed-dose schedules (e.g., chewing one piece for the first 30 minutes of every hour) to achieve blood nicotine levels adequate to prevent withdrawal. It is used for 3 months. Long-term dependence on the gum is uncommon.

Nicotine Lozenge

A nicotine lozenge whose pattern of nicotine delivery resembles the gum is sold without prescription in 2-mg and 4-mg doses. Smokers whose first cigarette of the day is smoked within 30 minutes of awakening should use the 4-mg dose; others use the 2-mg dose. In randomized controlled trials, it doubles cessation rates compared with a placebo lozenge. It is placed in the mouth between cheek and gum. Nicotine in the lozenge is gradually absorbed through the oral mucosa over 30–40 minutes. The user should not eat or drink when the tablet is in the mouth. The lozenge differs from the gum in that no chewing is required, making it easier to use properly. People with dentures or poor dentition who generally cannot use the gum can use the lozenge. A smoker uses a lozenge as needed to control cravings, usually every hour or two, and uses it for 3–6 months. A mini-lozenge formulation that is smaller and dissolves more rapidly than the original nicotine lozenge is now available.

Nicotine Inhaler

The nicotine inhaler, sold only by prescription in the United States, is a handheld device containing nicotine in a plug that is vaporized when the smoker inhales. The nicotine is absorbed by the oral mucosa rather than in the lungs. Therefore, the inhaler delivers nicotine in a pattern similar to the gum or lozenge with peak nicotine levels reached 20 minutes after the start of use. The inhaler mimics the hand-to-mouth behavior of cigarette smoking, a feature that appeals to some smokers. The inhaler doubles the cessation rate compared to placebo in randomized trials. Side effects are minimal; throat irritation and cough are the most common.

Nicotine Nasal Spray

Nicotine nasal spray is sold only by prescription. Nicotine is more rapidly absorbed from the nasal mucosa than it is through the oral mucosa, but less rapidly absorbed than through the lungs when a cigarette is smoked. The nicotine nasal spray doubles cessation rates compared with a placebo spray in randomized controlled trials, but has a high incidence of side effects (nose and throat irritation, watery eyes, sneezing, and cough). Careful instruction is required for its proper use. The dose is one spray in each nostril as needed; this delivers a dose of 1 mg of nicotine. It is used for 3–6 months.

Bupropion

Bupropion is an antidepressant with dopaminergic and noradrenergic activity. In its sustained-release form (Zyban, Wellbutrin SR), bupropion doubles smoking cessation rates compared with a placebo and is FDA approved for smoking cessation. The most serious side effect is a reduction in the threshold for seizure. The risk of seizure is 1 in 1000 patients or less, but the drug is contraindicated in patients with a seizure disorder or predisposition. Common side effects are insomnia, agitation, headache, and dry mouth. Doses of 150–300 mg/day for 7–12 weeks are effective for smoking cessation. The drug is started 1 week before the smoker’s quit date to allow for blood levels to stabilize before quitting occurs. Bupropion reduces but does not eliminate weight gain after smoking cessation (see section below “Weight and Smoking Cessation”), but the effect disappears when the medication is stopped. Nonetheless, this effect may appeal to smokers who are concerned about postcessation weight gain.

Varenicline

Varenicline is a selective partial agonist at the α4β2 nicotinic receptor, the subtype of nicotine receptor in the brain that appears to mediate nicotine dependence. It is thought to have a dual mechanism of action. As a partial agonist, it partly relieves nicotine withdrawal symptoms. In addition, if a smoker using varenicline smokes a cigarette, the drug blocks the nicotine in cigarette smoke from binding to the nicotine receptor, thereby making smoking less rewarding. In randomized controlled trials comparing the drug with placebo and with bupropion, varenicline produced a higher long-term cessation rate than both and nearly tripled the cessation rate compared with placebo. Nausea is the most common side effect, occurring in nearly 30% of subjects in clinical trials. In practice, it can often be managed successfully by taking with food and a full glass of water. Varenicline is used for 12 weeks at a dose of 1-mg bid, starting with a 1-week gradual up-titration in dose to minimize nausea. The quit date should be set at least 1 week after starting the drug to allow blood levels to stabilize before quitting occurs, but delaying the quit date until 4 weeks after starting the drug might produce even better results.

Concerns about varenicline’s safety appeared after the drug was marketed in 2008. In 2009, the FDA reviewed case reports for all smoking cessation drugs and reported that varenicline and bupropion, but not NRT, were “associated with reports of changes in behavior such as hostility, agitation, depressed mood, and suicidal thoughts or actions.” Bupropion and varenicline were both required to add boxed warnings about this to their labels. So far, an association between varenicline and behavior changes has not been observed in randomized clinical trials or observational studies of smokers starting varenicline. In 2011, the FDA reaffirmed their position that the benefits outweigh the risks in most cases. An association of varenicline with an increased incidence of cardiovascular outcomes such as heart attack was observed in one meta-analysis, but not in the second one. In both studies, the absolute risk of an adverse cardiovascular event was very low, with or without varenicline. Clinicians who prescribe varenicline should monitor patients’ behavior and mood, especially those with current or past psychiatric diagnoses. Combination NRT is an alternative for individuals in whom varenicline is considered potentially risky.

Nortriptyline and Clonidine

Nortriptyline, a tricyclic antidepressant, has demonstrated efficacy for smoking cessation in randomized controlled trials. A meta-analysis found that its efficacy resembled that of the atypical antidepressant bupropion. Nortriptyline is not FDA approved as a smoking cessation aid. Hypotension and dry mouth are the most common side effects. There is no evidence to support the use of any other antidepressants or any antianxiety agents for smoking cessation.

Clonidine, a centrally acting α-adrenergic agonist, is used to treat craving for psychoactive drugs other than nicotine. In randomized, placebo-controlled trials, both oral and transdermal clonidine reduced withdrawal symptoms and increased rates of cessation. Clonidine is not FDA approved for smoking cessation, and side effects (sedation, dizziness, and dry mouth) generally limit its use in practice.

Weight & Smoking Cessation

Smokers weigh 5–10 lb less than nonsmokers of comparable age and height. When smokers quit, 80% of them gain weight. The average weight gain of 10–15 lb (4.6–6.8 kg) poses a minimal health risk, especially when compared with the benefits of smoking cessation. Women and heavier smokers (>25 cigarettes per day) gain more than men and lighter smokers. The mechanism is incompletely understood, but a nicotine-related decrease in metabolic rate and possibly increases in food intake appear to be largely responsible. The best approach to the problem may be to help smokers accept a small weight gain and reassure them that the expected amount is less than they may fear. A vigorous exercise program reduces postcessation weight gain and promotes cessation. Smokers who use nicotine gum or bupropion gain less weight than those who quit with a placebo and this may help weight-concerned smokers to make a quit attempt.

Social Support

Smokers with nonsmoking spouses are more likely to quit than smokers whose partners smoke. Smokers whose efforts to stop are supported by partners, family, and friends are more likely to succeed than smokers without this support. Those who live with smokers can ask them to restrict smoking to outdoor areas to provide a smoke-free home. Formal cessation programs provide an additional source of social support that can be valuable when a smoker’s own environment is not supportive of quitting.

Depression and Other Psychiatric Disorders

Stopping smoking represents a loss for many smokers. Cigarettes have been reliable “companions” as well as coping tools. Transient sadness is common and requires no special treatment. Acknowledgment that this is normal can be helpful. There is, however, a strong association between smoking and mood disorders. Smokers have more depressive symptoms than nonsmokers and are more likely to have a history of major depression. Depressed smokers are less likely to stop smoking than nondepressed smokers, but smoking cessation treatments appear to work in smokers with mood disorders. Early evidence suggests that adding a mood management component to standard treatment might increase treatment success. Clinicians should be alert to the possibility of depression in smokers. If present, it should be treated concurrently with tobacco use. Smokers with a history of depression should be watched for the reemergence of symptoms during smoking cessation.

Substance Use

There is a high rate of smoking among individuals who abuse alcohol, cocaine, heroin, and prescription opioids. As with depression, substance abuse should be considered as a potential comorbid disorder in smokers who repeatedly try and fail to quit. Even among smokers who do not abuse alcohol, drinking is frequently an ingredient in relapse situations. Smokers attempting to quit are commonly advised to avoid alcohol temporarily after quitting.

Because smoking begins early in life, preventing young people from starting is a task for physicians who care for children and adolescents. The challenge for physicians taking care of adults is smoking cessation. Physicians have the opportunity to intervene with smokers, because each year they see an estimated 70% of the smokers in the United States. They also see smokers at times when their symptoms have caused them to be concerned about their health and, therefore, more likely to be willing to change their smoking behavior. For example, one-third of smokers stop smoking after a myocardial infarction; this can be increased with brief counseling by a physician or nurse. For women, pregnancy encourages smoking cessation. Approximately 30% of female smokers stop smoking while pregnant, although many resume smoking after delivery. Other smoking-related conditions may also provide “teachable moments” when smokers are more receptive to advice to stop smoking.

Providing brief advice to stop smoking to all patients seen in the office increases patients’ rates of smoking cessation. Although advice alone is effective, randomized controlled trials in general medicine and family practices have demonstrated that supplementing advice with brief counseling in the office is more effective. Counseling smokers in an office practice is as or more cost-effective than other accepted medical practices. Brief interventions prompt smokers to attempt to quit, and physicians should then make sure that smokers attempting to quit are linked to effective treatment.

Evidence-based clinical guidelines for smoking cessation treatment by primary care providers recommend that the primary care of adults should include a routine assessment of smoking status in all patients, strong advice to all smokers to quit, assessment of a smoker’s readiness to quit, assistance for those smokers who are ready to stop, and follow-up for all smokers. The guidelines have been organized into a five-step protocol for use in office practice (Table 21-2).

1. ASK: Someone on the clinical team should routinely ask all patients at every visit whether they smoke cigarettes and document smoking status in the health record.

2. ADVISE: Regardless of a smoker’s degree of interest in quitting, it is the physician’s responsibility to deliver clear advice to each smoker about the importance of stopping. The message should be strong and unequivocal; for example, “Quitting smoking now is the most important health advice I can give you.” If appropriate, advice should be tailored to the clinical situation, either current symptoms or family history. For example, smokers can be informed that they will have fewer colds or less asthma if they stop smoking. Advice is more effective when phrased in a positive way; for instance, emphasizing the benefits to be gained from quitting rather than the harms of continuing.

3. ASSESS: Assess a smoker’s interest in stopping. Categorizing smokers in this way is a clinically useful approach that helps the physician to determine which counseling strategy is appropriate and to set achievable goals. Although the clinician’s overall goal is to assist the smoker to stop permanently, a realistic goal for a single office visit is to move the smoker to the next stage of readiness to stop.

4. ASSIST: Help the smoker quit. The physician’s approach should vary according to the smoker’s readiness.

   • If the smoker is interested in quitting, the physician should ask whether they are ready to set a “quit date,” a date within the next 4 weeks when they will stop smoking. If so, the date should be recorded in the chart and on material given to them to take home. The physician should discuss with the patient what approach is most likely to be successful considering the smoker’s level of nicotine dependence and past experience in trying to quit. Both behavioral treatment and pharmacotherapy should be offered. Behavioral treatment can be provided by referring the smoker for group, individual, or telephone counseling for smoking cessation. Free telephone counseling for smoking cessation is accessible nationwide by calling a central number (800-QUIT-NOW). The physician should be prepared to discuss the management of barriers to cessation if the smokers ask. More intensive treatment is indicated for smokers who have been unsuccessful in previous attempts. The options include referral to a formal smoking cessation program and pharmacotherapy. Smoking cessation programs provide intensive training in behavioral smoking cessation skills combined with social support from the counselor and other group members. Combinations of pharmacotherapy and behavioral counseling are more effective than either one alone.

   • For smokers not interested in quitting or not ready to set a quit date, the physician should elicit the patient’s views about the benefits and harms of smoking to the individual smoker. With this perspective, the physician can provide missing information about health risks and correct misconceptions about the process of smoking cessation. The discussion should focus on short-term benefits rather than distant risks, and the physician should be prepared to discuss common barriers to smoking cessation. The clinician should advise the smoker not to expose family members to passive smoke and suggest that help is available when they are ready to quit.

5. ARRANGE: Randomized trials have demonstrated that arranging follow-up visits to discuss smoking increases the success of physician counseling. Smokers should be asked to return shortly after the quit date to monitor progress; this is especially important for smokers using pharmacotherapy, so that side effects and nicotine withdrawal symptoms can be monitored.

   • If smokers are not smoking at the follow-up visit, they should be congratulated but warned that continued vigilance is necessary to maintain abstinence. The level of nicotine withdrawal symptoms should be assessed, and if indicated, treated by starting or increasing pharmacological treatment. To help prevent relapse, patients should be asked to identify future situations in which they anticipate difficulty remaining abstinent. The physician can help to plan and rehearse coping strategies for these times. Further follow-up visits or telephone calls should be offered.

   • If the smoker has not been able to remain abstinent, the physician’s role is to redefine a failure into a partial success. The patient can be told that even 1 day without cigarettes is the first step toward quitting and be reminded that it takes time to learn to quit, just as it took time to learn to smoke. To help the patient learn from the experience, the physician should ask about the circumstances that preceded the first cigarette smoked after the quit date, what was learned from the experience that could be used for the next attempt to quit, and whether a new quit date should be set.

Health Care Systems

The responsibility for providing smoking cessation treatment in outpatient practice should not lie only with the physician. A system-level approach in which different members of the care team each have a specific role is effective and reduces the burden on the individual practitioner. In this model, the five tasks listed above are done collaboratively by different individuals with adequate training, institutional support, and reimbursement by health insurers. For example, a patient’s smoking status can be assessed by a staff member in the clinic or hospital before the physician sees the patient and a reminder left in the medical record to prompt the physician to discuss smoking. The physician’s prime role is to give advice to quit, assess readiness to quit, and direct the smoker to effective resources, such as medication, or community resources, such as telephone quitlines and formal cessation programs. Other personnel may assist the physician’s efforts in referral and provide counseling and medication instruction.