P7S Medical Review: Spring 1997, Vol.4, No.1
Smoking Cessation: The Role Of Primary Care Clinicians

Christine H. Shin, P&S '98

Columbia University College of Physicians & Surgeons

LH is a 54 year old white male newspaper reporter who would like to quit smoking. He smokes an average of 2 packs per day. However, when he is out of his usual routine, he notes that he is able to cut back significantly, as was the case during a seminar he attended recently. He has been trying to quit smoking for the last ten years. He attempted to quit several times, with the longest period of abstinence being 9 months. Inevitably, he starts smoking again during a time of stress in his life. Trying to quit is made more difficult because his wife's cigarettes are always lying around the house. They smoke the same brand.

LH's doctor recently diagnosed him with mild emphysema. This has rekindled his interest in quitting. He wants to become educated and increase his motivation to quit. He wants to collect self-help literature so that he can discuss quitting with his wife. He wants to see some "dead lungs". He knows that he can quit, but now he needs to learn how to stay quit.

LH's story is typical of many smokers. Millions of Americans continue to smoke despite the widely recognized accompanying health risks. 70% of US smokers report that they would like to quit and have made at least one serious attempt to quit in the past.¹ However, of the 20 million US smokers who try to quit each year, greater than 90% are smoking again one year later. Sadly, only 2-3% of smokers successfully become non-smokers each year.² Primary care clinicians are in an ideal position to significantly alter the smoking habits of their patients. Greater than 70% of smokers see a physician each year and many cite a physician's advice to quit as an important motivating factor.¹ Yet, clinicians have not intervened consistently.¹ Primary care providers need to play a much more prominent role in this national health problem.

Most physicians are familiar with the diagnosis and treatment of smoking-related diseases. Smoking is directly responsible for one in seven deaths in the US, from causes such as chronic obstructive pulmonary disease, coronary artery disease, cardiomyopathy, peripheral vascular disease, or cancer (lung, pancreas, bladder, to name a few).³ Physicians recognize that smoking is the most important preventable cause of death in the US but they do not consistently address tobacco use among their patients. Only about half of current smokers recall having been asked about their smoking status or being urged to quit by a doctor.¹ This lack of consistent intervention may be due to a combination of factors: a lack of formal training in effective cessation techniques, a perceived lack of skills, frustration due to low success rates, time constraints, lack of reimbursement, or even a belief that smoking cessation is not an important professional responsibility.^1,4

Studies indicate that with a little training, physician intervention increases successful quitting.^4,5 In 1984, the National Cancer Institute funded five randomized, controlled trials to develop brief intervention protocols for smoking cessation. The interventions used are best described as "physician-guided self-help programs". They included techniques such as brief counseling, providing self-help booklets, and prescribing nicotine gum. The trials involved 30,000 patients and 1,000 physicians in a variety of outpatient settings. The results showed that training physicians to use brief interventions resulted in more effective care of smoking patients. Patients of trained physicians were more likely to quit than patients of non-trained physicians. In addition, there were significant increases in success rates when the trained physicians were routinely reminded to intervene; the patients of these physicians were six times more likely to quit than the usual care patients.⁴

Recommendations for effective smoking cessation intervention are given in How to Help Your Patients Stop Smoking: a National Cancer Institute Manual for Physicians.^4,6,7 This manual describes a successful intervention protocol consisting of the Four A's: ask, advise, assist, and arrange. Two additional A's can be added from the Doctors Ought to Care (DOC) model of medical activism: assess and activate. Therefore, physicians can use a six-step model to aid their patients in smoking cessation: ask about smoking at every visit, advise all smokers to stop, assess readiness and motivation to quit, assist the patient in stopping, arrange follow-up visits, and activate the patient and the community.⁷ As this model clearly shows, quitting is a process that takes place over time. Therefore, intervention should be provided every time the patient is seen. Typically, this can be accomplished in less than three minutes per visit.⁴

1. ASK ABOUT SMOKING AT EVERY VISIT: It is important to ask every patient about their smoking history. An office-wide system should be implemented that identifies and documents all smokers. For example, vital signs can be expanded to include tobacco use. Alternatively, tobacco-use status stickers may be placed on a patient's chart or smoking status indicated by a computerized reminder system.¹

A more detailed smoking history should also be taken.³ How many cigarettes does the patient smoke per day? How many years have they smoked? What was the age and circumstance of starting? Further questions can reveal why smoking has been maintained. Both pharmacological and psychological models have been proposed to explain smoking maintenance. In the pharmacological model, patients continue to smoke for the rapid and pleasurable effects of nicotine, such as sustaining desirable mood or attentional states, or making stressful situations easier to handle.² Other patients smoke to avoid withdrawal symptoms such as craving, irritability, restlessness, anxiety, impaired concentration, disturbed sleep, or gastrointestinal distress.³

In contrast, the psychological model regards smoking as a learned behavior that persists because of positive reinforcement. Patients may continue to smoke in order to appear social, to relieve boredom, to enhance the pleasure of drinking alcohol or coffee, or even to keep their hands busy. The behavior is also maintained by strong cues from the environment, such as living with a spouse who smokes or being in a situation which has become strongly associated with smoking, such as finishing a meal, driving a car, or talking on the telephone.³ Information about why a patient has continued to smoke provides valuable insight into how best to design a smoking cessation plan and how to avoid relapse after the patient has successfully quit.

Finally, further questions can determine the extent of a patient's pharmacological dependence on nicotine. There is a good correlation between scores on the Fagerström Test for Nicotine Dependence (Figure 1) and the severity of withdrawal symptoms, difficulty in abstaining, and speed of relapse.² The timing of the first cigarette of the day identifies the smoker who needs to boost blood levels of nicotine after sleeping. The person who smokes while ill or in a forbidden place (church, library, cinema) generally has an addiction that overrides physical or social bounds.³ Scores of more than six on the Fagerström Test generally indicate a high degree of physical dependence to nicotine and possibly the need for higher doses of nicotine replacement.²

2. ADVISE ALL SMOKERS TO STOP: All smokers should be urged to quit in a clear, strong, and personalized manner.¹ A majority of smokers say they would try to stop smoking if they were asked to do so by a physician. However, many smokers do not recall ever hearing this advice.⁴ Therefore, the physician's message must be memorable and easy to understand, e.g., "As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health."¹ Personalizing the message makes it even more effective. Smokers are more likely to quit if they have information about the specific effects smoking has had or can have on their lives.⁴ For example, the message could be tied into the patient's present health or illness, the social or economic costs of tobacco use, or the impact of smoking on children and others in the household.¹

3. ASSESS READINESS AND MOTIVATION TO QUIT: The process of smoking cessation can be broken down into four stages. Pre-contemplation is the stage when a smoking patient is not thinking about quitting. Contemplation is the time when a patient is seriously considering quitting. Action is the stage where the patient is taking the appropriate steps to cessation. Maintenance is the stage where the smoker has successfully quit smoking and is avoiding relapse.⁴ A physician's role within this model is to identify which stage of cessation the patient is in, and to provide encouragement and assistance in order for the patient to progress to the subsequent stages.

Motivation is the key variable in a behavior change such as smoking cessation. Because the patient will likely experience withdrawal symptoms and strong cravings to smoke, a strong and sustained desire to quit smoking is critical to success. A physician alone usually will not be able to create and maintain such a desire.⁴ Rather, the motivation to quit will be based on input from multiple sources, including friends, family, the media, the actions of elected officials, and the patient's perceived health. As the social acceptability of smoking decreases and more anti-smoking public policies and media campaigns are implemented, physicians will be seeing an increasing number of smoking patients who are self-motivated to quit.⁴

Physicians should be aware of "windows of opportunity" when cessation rates can be very high. Fear of imminent death is a highly motivating factor in most patients. Cessation rates have been shown to be as high as 60% among survivors of recent myocardial infarctions.⁴ Onset of other acute smoking-related illnesses, such as asthma attacks or GI hemorrhages, also provide optimal times to initiate cessation.³ Many pregnant women are motivated to quit, recognizing the adverse effects smoking has on the fetus.¹ Cessation can be particularly successful in hospitalized patients for two reasons. First, patients tend to be highly motivated to quit when they realize their vulnerability to the adverse health effects of smoking. Second, hospitals are smoke-free environments that force the patient to at least temporarily stop smoking. All hospitalized smokers should be offered assistance to quit smoking and to maintain abstinence after discharge.¹ It is important for physicians to recognize and use these opportunities for cessation, as there is a high likelihood of success, even in the previously reluctant patient.³

The physician should ask all smoking patients for a commitment to quit. If the patient is willing to make a quit attempt, assistance should be provided (Step 4). If the patient is not willing to make a quit attempt, the reasons for the unwillingness should be elucidated. An intervention consisting of the Four Rs (relevance, risks, rewards, and repetition) may enhance motivation to quit.¹ As mentioned previously, the message to quit will be more effective if it is relevant to the patient's personal situation. For example, the physician may address the patient's concerns, health, family or social situation (children in the house), or prior quitting experience. The patient should be asked to identify the risks of smoking. These may include acute risks (shortness of breath, asthma, impotence, infertility, pregnancy-related risks), long-term risks (heart attacks, strokes, chronic bronchitis, emphysema, lung and other cancers), or environmental risks (higher rates of smoking in children of smokers, lung cancer in spouse and children, and higher incidence of sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers). The physician may highlight those health risks which seem most relevant to the patient. Next, the patient should be asked to identify the rewards of cessation. Examples may include improved health, increased sense of taste and smell, saving money, feeling better about oneself, better breath, setting a good example for children, having healthy infants and children, freedom from addiction, and better exercise tolerance and performance. Again, the physician can highlight those rewards which apply to the patient. Finally, this motivational intervention should be repeated every time the patient is seen.¹

4. ASSIST THE PATIENT IN STOPPING: Once a smoking patient has made a commitment to quit, the physician and patient should work together to formulate a smoking cessation plan. The goal at this point is to alter the patient's knowledge, attitude, and skills. This can be accomplished through a number of attitude-changing and skill-building interventions.³

The first step is to pick a quit date. There is evidence that patients who pick a quit date are more likely to make a serious attempt to quit.⁴ The date should be within 2 weeks of the visit, but not too soon after the visit, because the patient needs time to prepare to stop.^1,3,4 The patient should inform family, friends, and co-workers that they are quitting and ask for encouragement and support. The environment should be prepared by removing all cigarettes and all reminders of smoking from it. The patient should avoid smoking in places where he or she spends a lot of time (e.g., home, car).¹ A "smoking diary" can be kept simply by attaching a piece of paper to a pack of cigarettes with a rubber band and writing down the circumstances within which each cigarette is smoked. This allows the patient to self-examine his smoking behavior and to identify situations which "trigger" smoking urges.³ The patient should review previous attempts to quit in order to determine what helped and what led to relapse.¹ Giving the patient a stop-smoking prescription which includes the quit date reinforces the message that this is an important medical intervention for a serious health problem.³

To quit smoking is very difficult. A smoker must not only overcome a physical and chemical dependence on nicotine, but they must conquer a behavioral addiction. A successful smoking cessation plan must address both aspects of the addiction: psychological as well as pharmacological. In order for a smoker to overcome the behavioral addiction to smoking, he or she must be aware of and anticipate challenges to the quit effort. The patient must be educated about what to expect after cessation and develop coping skills in order to make it through times of weakness.^1,4

For example, the majority of smokers will gain weight after quitting. This is due to a number of factors including the improved taste of food as well as the change in body metabolism caused by the absence of nicotine. The average weight gain is approximately 5 pounds.⁴ It is important to warn the patient of this possibility so that he or she is prepared for its occurrence, and less likely to relapse if it does occur. It should be stressed that the benefit of giving up cigarettes far outweighs the drawbacks of putting on a few pounds.⁸ If the patient is very worried about the possible weight gain, the physician can advise snacking on low-calorie foods and increasing exercise.⁴ Cinnamon sticks can be particularly useful because they are shaped like cigarettes and many ex-smokers find the taste to be very satisfying. Taking a walk instead of taking a smoking break can be an effective way to increase exercise while getting fresh air and distracting the smoking urge at the same time. It is generally not recommended that patients try to lose weight until several months after cessation, when the risk of relapse is less likely.⁴

There are a number of self-help pamphlets which provide this kind of useful information to smokers. They are available through federal agencies including the American Cancer Society, the American Lung Association, and the National Cancer Institute.⁴ One such publication, Clearing the Air: How to quit smoking and quit for keeps,⁸ is a 24 page booklet which guides the patient through the various steps of quitting, from thinking about quitting to actually quitting and then to staying smoke-free. It provides a number of helpful hints about effective cessation techniques as well as tips about how to avoid temptation, how to cope with withdrawal symptoms, and how to resist situational triggers that create the urge to start smoking again.⁸ These kinds of brochures have successfully helped millions of people to stop smoking, and the importance of the information contained within them should be stressed to the patient.⁴

Some additional points about avoiding relapse should be stressed during the office visit. ¹Complete abstinence is essential for success. Any smoking during the first two weeks of cessation often leads to failure.² The patient should be told "not even a single puff after the quit date". Alcohol use is highly associated with relapse and the patient should consider limiting alcohol use during the quitting process. The presence of other smokers in the household is also associated with low success rates and efforts should be made to either involve that person in the quitting process or to ask them to smoke only outside of the house.¹

A number of studies have shown that nicotine replacement typically doubles or triples the rates of cessation success.^1,2 Withdrawal symptoms such as anxiety, difficulty concentrating, headache, abdominal discomfort, insomnia, and strong cravings for cigarettes play a significant role in cessation failure. These symptoms typically begin within hours of the last cigarette, are most severe in the first two to three days, and slowly diminish over two to three weeks.⁴ Rates of relapse are very high when withdrawal symptoms are at their peak.^2,4 Nicotine replacement therapy reduces the severity of these withdrawal symptoms and allows the patient to function while learning to live without cigarettes.² Superior cessation rates have been demonstrated through treatment combining behavioral therapy with nicotine replacement, but not if the replacement therapy is used alone. Therefore, replacement therapy should be used only as an adjunct to a strong behavioral modification program.³

The two forms of replacement therapy available today are the nicotine patch and nicotine gum. The patch was introduced in 1991, and since then, numerous studies have shown its effectiveness in increasing rates of smoking cessation. One study reports a four-fold increase in cessation after two years in the patch-treated group compared to the placebo group.² Standard treatment involves applying the highest dose patch (e.g., 21 mg/24 h) to the skin on the morning of the quit date. A new patch should be applied every morning, rotating the site of application in order to decrease adverse skin reactions. The highest dose patch is worn for four weeks. The mid-range patch (e.g., 14 mg/24 h) is then worn for two weeks, followed by the lowest dose patch (e.g., 7 mg/24 h) for two weeks. Such an 8 week treatment program has been found to be just as efficacious as longer programs. Adverse effects may include mild pruritis and edema at the site of patch application or sleep disturbances if the patch is worn at night.^1,2

Polacrilex nicotine chewing gum is the older form of nicotine replacement therapy. Each piece of gum contains either 2 or 4 mg of nicotine. The patient should be instructed to chew the gum until they sense a "peppery" taste, then park the gum between the cheek and the gum for 30 minutes, and rechew and repark every minute or so. Acidic beverages decrease the buccal absorption of nicotine, so the patient should be warned not to drink soda, coffee, or juices immediately before or during chewing.^1,2 Treatment is more effective if the patient is placed on a fixed dosing schedule, such as one dose per waking hour, than if the patient chews only when craving a cigarette.² Side effects such as jaw fatigue, hiccuping, burping, and nausea can be prevented with proper chewing technique.² Other side effects may include dizziness, nausea, or abdominal distress.³

Both forms of nicotine replacement therapy have been found to be safe and effective, so all smokers who wish to quit should be offered pharmacological treatment. However, precaution should be taken in treating pregnant patients and patients with cardiovascular disease. These patients should be treated with nicotine replacement only after a careful consideration of the risks and benefits involved.¹ In general, the patch is the preferred form of treatment because it is easier to use, and therefore has better patient compliance. Indications for gum use include patient preference, failure of cessation with the patch, or severe skin reactions at the site of patch application.¹ Light smokers who smoke less than 10-15 cigarettes per day may be given lower starting doses of replacement therapy. Those who smoke less than 5 cigarettes a day typically do not experience withdrawal symptoms upon quitting, and therefore, do not require replacement therapy.² For highly addicted smokers who relapse after using standard replacement treatments, data suggest that combination therapy may be effective. The patch would provide a stable blood level of nicotine, while the polacrilex gum could boost levels for momentary needs.^2,9

5. ARRANGE FOLLOW-UP VISITS: Relapse is a typical part of cessation. Many smokers have a history of several serious but unsuccessful cessation attempts.² Each year, many millions of American smokers are sufficiently motivated to make a quit effort, however, less than 10% typically succeed. Therefore, relapse is a major problem that needs to be adequately addressed, as it is responsible for severely slowing the potential decline in smoking prevalence in the US.⁵

Effective follow-up is extremely important and greatly increases a patient's chances of successfully quitting.^4,7 Informing a patient of follow-up plans also tends to improve compliance.² Follow-up can be done at any time, but there are critical time points which must be covered. Sending a quick note or making a brief call right before the quit date can reinforce a patient's decision to stop smoking. Rates of relapse are extremely high two to four days after quitting, when withdrawal symptoms are at their peak.² A visit to the office during this time can be extremely helpful for many patients. Setting up such visits in the first few days, first few weeks, and first few months of cessation can provide more manageable short-term goals than "forever".⁴ Early follow-up visits are also useful to encourage the patient, to detect ineffective use of medication, and to discuss problems encountered or anticipated in the quitting effort.^2,4 The quit rate has been shown to improve proportionately as the number of follow-up visits increases.⁴

If a patient has relapsed, the physician should find out why the patient started smoking again and provide strategies that the patient can use to avoid or cope with these trigger situations.⁴ The discussion can be initiated with a simple question such as "Where did your first cigarette come from?". Some common reasons for relapse include withdrawal symptoms, weight gain, "stress" at work or at home, alcohol intoxication, and social pressure. Asking the patient, "How would you deal with that situation if it happened again?" or "How could you avoid that situation in the future?", prompts the patient to think about coping skills.⁴ When patients realize that they can learn from the relapse and have a greater chance of succeeding in future attempts, they are often willing to try again.⁴

The physician may want to address specific reasons for relapse by providing specific interventions. For example, if the patient reports prolonged craving or other withdrawal symptoms, the clinician could consider extending nicotine replacement therapy or instituting combination patch and gum therapy. The physician could make dietary, exercise, or lifestyle recommendations if weight gain is the major reason for relapse. If smoking cessation has precipitated a negative mood or depression, the patient could be treated with an appropriate medication or referred to a specialist.¹ The rates of relapse tend to be very high in post-partum women who quit during pregnancy. The clinician could try to re-emphasize the increased incidence of SIDS, respiratory infections, asthma, and middle ear disease in infants raised in smoking households.¹

6. ACTIVATE THE PATIENT AND THE COMMUNITY: Using Doctors Ought to Care (DOC) strategies to "activate" patient anger against the tobacco industry appears to be useful in motivating smokers to quit. When patients see that they have been misled by the dishonesty, deception, and calculated efforts to profit by the tobacco industry, many will fight harder to gain back the control they have lost to tobacco.⁷

A Smoking Cessation Strategic Planning Chart (Figure 2) has been proposed by Usatine et al as a way to comprehensively approach smoking cessation.⁷ It provides an effective way to rapidly chart a detailed smoking history and smoking cessation plan. Putting it into practice is simple. All patients should be asked about their smoking status while the vital signs are being taken. If a patient smokes, the planning chart should be completed by the physician and the patient and then placed in the patient's medical record. The questions addressed by the planning chart serve the dual purpose of obtaining a detailed smoking history and providing insight into how best to design a cessation plan. The number of pack-years provides an indication of the patient's addiction status. Information about previous attempts to quit signify motivation but lack of skills.³ Questions about smoking-related health problems reinforce the benefits of quitting. Information about the patient's household provides insight into possible social supports or possible triggers for relapse. Other environmental triggers, such as stress, alcohol, or socializing can be elucidated and addressed.⁷ Finally, a plan and its various components, nicotine replacement, behavioral modification, and follow-up, can be documented.⁷

Smoking is a major public health issue which warrants intervention. In 1964, the US Surgeon General publicized smoking as the most important preventable cause of death.³ It is estimated that one cigarette is equivalent to five minutes less of life, which translates into 5 to 8 years lost for many heavy smokers.³ However, many of the adverse effects of smoking can be reversed simply by quitting. Within 12 hours of the last cigarette, the body begins to heal itself.⁷ In myocardial infarction survivors, smoking cessation results in a 50% reduction in the rate of recurrence or death.³ The risk of lung, esophageal, laryngeal, and bladder cancers decrease during the first five years of cessation, eventually equaling the risk of a nonsmoker after 15 years.³

25% of Americans smoke. Of these, 70% wish to quit, but have been unsuccessful in their attempts.¹ Studies demonstrate that the intervention of primary care providers can greatly increase success rates.^1,4 Physicians need to make it their responsibility to intervene consistently in smoking cessation. Those who can help their smoking patients to quit have provided a life-saving service.

1. Smoking Cessation Clinical Practice Guideline Panel and Staff. The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA 1996;275(16):1270-80.

2. Henningfield JE. Nicotine medications for smoking cessation. N Eng J Med 1995;333(18):1196-203.

3. Kelley WN, ed. Smoking Cessation: Clinical Evaluation and Management of the Smoker. Textbook of Internal Medicine. Philadelphia: J.B. Lippincott Company, 1992:2093-97.

4. Manley MW, Epps RP, Glynn TJ. The clinician's role in promoting smoking cessation among clinic patients. Med Clin N A:1992;76(2):477-94.

5. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States: Do cessation programs help? JAMA 1990;263(20):2760-65.

6. Glynn TL, Manley MW. How to help your patients stop smoking- a National Cancer Institute Manual for Physicians. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1990. NIH publication No. 909-3064.

7. Usatine RP, Richards JW Jr. Counseling patients for smoking cessation. J Fam Pract 1995;40(6):562.

8. National Cancer Institute. Clearing the Air- How to quit smoking and quit for keeps. Washington DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1995. NIH publication No. 95-1647.

9. Hughes JR. Treatment of nicotine dependence. Is more better? JAMA 1995;274(17):1390-1.