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BETHESDA, MD--What can physicians really do to help their patients quit smoking? More than they may think, a new evidence-based guideline suggests.[1]

The new guideline, released by the US Public Health Service, describes current clinical interventions for alleviating tobacco dependence. Titled Treating Tobacco Use and Dependence, the document updates a smoking cessation guideline released in 1996 by the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research).

"The new guideline provides information on innovative counseling strategies that work, including telephone counseling and other techniques," explained Michael C. Fiore, MD, MPH, in a press briefing.[2] "It also contains evidence-based information about the effectiveness of new medicines that were not approved by the Food and Drug Administration when the original guideline was issued, and [it] urges that every tobacco user who is motivated to quit be provided with one of these medicines in the absence of contraindications," said Dr. Fiore, who is head of the guideline panel and Director of the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School in Madison.

BRIEF INTERVENTIONS

The guideline recommends a protocol of brief interventions for all physicians to use with their patients. The protocol begins with the "5 A's":

Ask about tobacco use. Implement an officewide system to identify and document tobacco use for every patient at every visit.

Advise patients to quit smoking. Use a clear, strong, and personalized approach. An opening statement might be, "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."

Assess the patient's willingness to stop smoking. If the patient is willing to make an attempt at this time, provide support and assistance.

Assist the quit attempt by providing appropriate counseling and pharmacotherapy. Set a quit date, ideally within two weeks.

Arrange follow-up, preferably within the first week after the quit date. A second follow-up within the first month is recommended. Schedule further follow-ups as indicated.

The guideline recommends three types of counseling and behavioral therapies: helping smokers to recognize situations that increase the risk of relapse and to develop coping skills, providing social support as part of treatment, and arranging social support outside of treatment. The effectiveness of these treatments increases with minutes of contact.

PRESCRIBING PHARMACOTHERAPY

According to the guideline, almost all smokers trying to quit are candidates for pharmacotherapy. The exceptions include patients with medical contraindications, those smoking fewer than 10 cigarettes per day, pregnant/breastfeeding women, and adolescent smokers.

"We identified five first-line medications that reliably increase long-term quit rates," explained Dr. Fiore. "Only two of them, the nicotine patch and nicotine gum, were recommended in 1996. The new medications include the nicotine inhaler, the nicotine nasal spray, and the non-nicotine pill bupropion."

The data are insufficient for these agents to be ranked. Thus, the guideline recommends that the choice of first-line pharmacotherapy be guided by factors such as clinician familiarity, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy, and patient characteristics (eg, a history of depression or concerns about weight gain).

Clonidine and nortriptyline are appropriate second-line pharmacotherapies and should be considered for patients for whom first-line drugs are contraindicated or for those who are unresponsive to first-line medications, according to the guideline. Patients should be closely monitored for side effects associated with any of these agents.

The guideline advises that lighter smokers (those who smoke only 10 to 15 cigarettes per day) can often be treated with a lower dosage of the nicotine medications than is normally used. However, no dosage adjustments are required for sustained-release bupropion.

The guideline also suggests that long-term treatment (six months or more) may be appropriate for smokers who suffer from persistent withdrawal symptoms or who request long-term therapy. "The use of [nicotine replacement] medications long-term does not present a known health risk. Additionally, the FDA has approved the use of bupropion SR for a long-term maintenance indication," the protocol states.

UNWILLING TO QUIT

The guideline points out that smokers unwilling to quit may lack specific information about the harmful effects of tobacco, may not have the required financial resources, or may be demoralized because of a previous relapse. In such cases, physicians should consider motivational intervention focused on the "5 R's":

Relevance: Indicate to the patient why quitting is relevant to his or her situation. According to the guideline, motivational information "has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (eg, having children in the home), health concerns, age, gender, and other important patient characteristics (eg, prior quitting experience, personal barriers to cessation)."

Risks: Ask the patient to identify potential risks of tobacco use; highlight those that seem most relevant to the patient. The guideline states, "The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or … [using] other forms of tobacco (eg, smokeless tobacco, cigars, and pipes) will not eliminate these risks." The guideline also recommends that the clinician point out both the acute and long-term risks of smoking.

Rewards: Ask the patient to identify potential benefits of stopping tobacco use, highlighting those of greatest relevance. Underscore such benefits as improved health, improved sense of taste, and cost savings.

Roadblocks: Ask the patient to identify barriers or impediments to quitting and cite aspects of treatment (eg, problem-solving, pharmacotherapy) that can be used to address these barriers.

Repetition: Repeat the motivational information every time an unmotivated patient visits your office. According to the guideline, "tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful."

--Stanley Nelson

References
1. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence [Clinical Practice Guideline]. Rockville, Md: US Department of Health and Human Services, Public Health Service; June 2000.
2. Fiore MC. Treating Tobacco Use and Dependence: A Public Health Service Practice Guideline [press briefing]. Washington, DC: US Public Health Service; June 27, 2000.

 

Preventing Relapse

Because of the chronic relapsing nature of tobacco dependence, the guideline recommends offering relapse interventions. Clinicians can institute either a minimal relapse prevention program or a prescriptive plan. For example, in a minimal program, the physician might: Congratulate the patient on any success in remaining abstinent and encourage him or her to continue abstinence. Use open-ended questions designed to initiate patient problem-solving. One such question might be: "How has stopping tobacco use helped you?" Discuss the problems encountered or anticipated threats to maintaining abstinence. In the prescriptive intervention, the patient identifies problems that threaten abstinence. Problems that are likely to be mentioned include: Negative mood/depression: Provide counseling, prescribe appropriate medications (eg, bupropion SR or nortriptyline), or refer the patient to a specialist. Strong/prolonged withdrawal symptoms: Consider extending the use of an approved pharmacotherapy or adding/combining pharmacologic medications to reduce strong withdrawal symptoms. Weight gain: Acknowledge that some weight gain is common after smoking cessation. Emphasize the importance of physical activity and a healthy diet. Smokers who are greatly concerned about weight gain may benefit from bupropion SR or nicotine replacement therapies (in particular, nicotine gum), both of which have shown some benefit in delaying postcessation weight gain. Flagging motivation/feeling deprived: Reassure the patient that such feelings are common. Probe to learn if the patient has engaged in periodic tobacco use. Stress that resuming smoking--even a puff--will increase urges and make quitting more difficult. --Stanley Nelson

Surgeon General's Report

United States Surgeon General David Satcher, MD, PhD, believes that smoking rates can be cut in half by 2010 if antismoking programs using the approaches summarized in Treating Tobacco Use and Dependence are fully implemented. Dr. Satcher made this announcement in Chicago at the 11th World Conference on Tobacco or Health, where he released Reducing Tobacco Use,[1] the first Surgeon General's report to provide an in-depth analysis of the effectiveness of various methods to reduce tobacco use. The report recommends that physicians, public health officials, and legislators: Implement effective school-based programs, combined with community and media-based activities. Such efforts can prevent or postpone smoking onset in 20% to 40% of adolescents. Fewer than 5% of schools nationwide implement the major components of school guidelines recommended by the Centers for Disease Control and Prevention. Change physician behavior, medical system procedures, and insurance coverage to encourage widespread use of state-of-the-art treatment of nicotine addiction. The report shows that brief physician advice to quit smoking can double or quadruple normal quit rates, while a combination of behavioral counseling and pharmacologic treatment can boost success as much as 10-fold. Pass and enforce strong regulations to promote clean indoor air. Improve tobacco warning labels; the labels used in the United States are less prominent than those required in other countries, such as Canada and Australia; US labels contain very little information regarding the ingredients, additives, and potential toxicity of tobacco products. Increase tobacco prices and excise taxes. Evidence presented in the report suggests that a 10% increase in price will reduce overall cigarette consumption by 3% to 5%. However, both the average price of cigarettes and the average cigarette excise tax in the United States are well below those in most other industrialized countries. --Kristin Della Volpe

Reference 1. US Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000.

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