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Smoking Cessation in Primary Care

Posted By Peter Fifield, Thursday, November 19, 2009
Updated: Wednesday, June 01, 2011

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 is the number one thing our patients can do to better their health. The problem: tobacco is extremely addictive. Back in the 80’s C. Everett Koop declared 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.

Assist: 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”.

If 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 inhalers.

The second task is to set a quit date; preferably with in two weeks. This takes advantage of the patient’s current motivation level. If possible get the person to slowly cut down the number of cigarettes they smoke each day. I typically encouraged my clients to reduce by one cigarette each day for two 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 the 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 services.

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.

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r says...
Posted Friday, July 08, 2011
Smoking cessation is a bugaboo for me. I actually feel pretty confident in my ability to help deconditioned patients get more active, but I can't say the same for tobacco users. It is an addicting, pernicious chemical. I can probably count on 1 hand the number of people with whom I counseled and now feel confident that they quit smoking and stayed off the pack.



I definitely think a counseling approach is key, though. It's amazing to what degree people organize their lives around smoking. It's rare to see a smoker married to a non-smoker or to see a non-smoker outside in the rain commiserating with smoking friends on a cigarette break.



Being a believer in the nanny state, I do think that social interventions are equally as important. I would continue to tax tobacco at a higher rate, make all public spaces smoke free, and charge people a higher insurance deductible. Yes, this is all punitive, but it is also highly effective, see http://en.wikipedia.org/wiki/Smoking_ban
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