The facts regarding the pernicious nature of smoking, second
and third hand smoke (http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke) are
abundant and clear. Tobacco use is
the leading cause for preventable morbidity and mortality and quitting
number one thing our patients can do to better their health. The
problem: tobacco is extremely addictive. Back in the 80’s C. Everett
tobacco "as addictive as heroin and cocaine”. For many reasons an
integrated primary care setting is an excellent
place to help patients end their nicotine addiction.
Although there is no silver bullet for smoking cessation,
there is a lot that can be done. The United States Public Health Service
(USPHS) recommends the Five A’s approach. I added one of my own (Accept). The first thing (as I see it) is to accept that quitting smoking is very
difficult and the relapse rates are very high; ranging from 60-98%. Acceptance of the difficult nature of smoking
cession can retard potential cynicism and also allow for a level of empathy for
that same patient who has failed time and time again. Acceptance also facilitates patience, knowing
that relapse is to be expected.
Ask. This is the first of the USPHS’s Five
A’s. Asking occurs, every time the
patient presents in the primary care setting. Most professionals agree, that inquiring about tobacco use should be done
every visit. Kreuter et al. (1997) state that only 55% of smokers are
encouraged to quit smoking by their providers. This is the beginning of an obvious problem—If we do not know who is
smoking, how can we help them quit.
Advise: This one is not so
simple. Although a firm and clear statement regarding
the reasons to quit is advised during every visit, some research has
shown that repeated advice to quit can damage the patient/provider
relationship http://www.bmj.com/cgi/content/abstract/316/7148/1878 . So there is a fine line we must walk here—ask
enough but not too much. The Behavioral Health Specialist (BHS) or other
integrated practitioner can take a patient centered approach to facilitate this
interface. This interaction should focus
on the patient’s ambivalence regarding smoking. Providers possess the skill base
to perform this task but the major reasons providers report not addressing
patient smoking habits in the primary care setting is due to lack of time.
Assess: Simply asking if the patient smokes, has ever smoked,
or is currently smoking is just the beginning. If the patient is ready to
quit then skip to the next step--Assist. If the patient tells you that
they have no intention to quit, then educate them of the dangers of smoking and
move on with the visit. We want to build alliances here, not half hearted
quitting attempts begun to appease the PCP.
If a patient is contemplating quitting then involve the BHS to use MI to
evaluate the patient’s stage of change. This
is the perfect time to build on discrepancy if the patient is ambivalent.
For those smokers who have already quit, find out how long it has been and
continue to support them. Data shows that 44% of all relapses with tobacco
occur before the two week mark.
If a patient is ready to quit they will typically state their readiness,
conversely, the patient that is not will most likely tell you "No I like
smoking”. Some patients however are literally afraid to disappoint and
will go to the extent of taking a medicating such as Chantix or Zyban and still
continue smoking. I’ve had interviews w/ patients mid-way through a
Chantix treatment tell me "Oh yah I still smoke, I just take these things
[pills] so the provider will leave me alone but please don’t tell them”.
the patient is ready to quit a few things should now occur. If
appropriate, the PCP can discuss pharmaceutical
interventions with the patient. The CDC reports that the chances of a
person successfully quitting doubles (from 5% to 10%) if a pharmaceutical
intervention is used. Medications such as Chantix and Zyban are often
used as well as nicotine replacement therapy (NRT) such as the patch, gum and
second task is to set a quit date; preferably with in two weeks. This
advantage of the patient’s current motivation level. If possible get
person to slowly cut down the number of cigarettes they smoke each day.
typically encouraged my clients to reduce by one cigarette each day for
weeks (storing them in a clear plastic bag so they know how many are
left) while the Chantix takes effect. By the time they actually reach
quit date, they have reduced down to 5 or so cigarettes per day.
Thirdly, discuss your state or
national quit line options. The states
of Maine actually
offers their residents four free telephone counseling sessions and free NRT. Many online sites exist as well. Some are: http://whyquit.com,
http://www.way2quit.com, http://www.trytostop.org and http://www.quitnet.org.
Lastly, consult with the patient and PCP
regarding comorbid mental health issues. This is where the integrated concept of BHS really shines. As with most
comorbid diagnoses, the motivation to address them are significantly decreased
by the presence of depression. Similarly, if people are suffering form anxiety, quitting smoking may be
seen as impossible. The BHS can play a
significant role in treating mental health related issues. Furthermore; tobacco
abuse is highly correlated with other substance abuse issues. In our clinic we are fortunate enough to have
two substance abuse counselors on site, integrated into our primary care
Arrange: Follow up sessions with a BHS can be
scheduled at this time. Fiore et al.
(2000) have shown that follow up interventions totaling 30-90 minutes, can
increase over-all abstinence rates by approximately 31%. Brief 15 minute counseling sessions, ranging
from 2-6 visits each, combined with medications or NRT work best in the primary
care setting for the treatment of nicotine addiction.