So what good will doctor’s advice do? Approximately 75% of all adults in the United States visit a physician at least once annually; the average yearly number of physician patient contacts is five. Furthermore, physicians have yearly contact with at least 70% of all adult smokers. Studies have documented that although doctors believe that helping patients to quit smoking is the most important thing they could do for them. The majority are pessimistic about their ability to do so. In fact, only 4% believe they can bring about a significant change in smoking behavior.
60-120 seconds of clear, unequivocal advice about the importance of quitting given directly by you to your patients, if accompanied by an educational handout and the comment that you will follow up on the patient’s smoking status, can produce a sustained abstinence rate of about 5%. While that may sound small, it is about a seventeen-fold increase in one-year continuous abstinence over that achieved with no intervention.
Another study found that if you follow your 1-2 minutes of advice with two follow-up visits, the one-year abstinence rate rises to approximately 15%. If you further add a prescription of nicotine polacrilex (Nicorette) to the regimen of advice and follow-up visits, the one-year abstinence rate improves once again.
Furthermore, if patients who smoke come to your office or are brought to the hospital because of an acute smoking-related symptom or emergency, such as a myocardial infarction, your advice will convince between 50-65% of these people to abstain from cigarettes for at least one year. And if they abstain for one year, they are likely to quit for life.
Your presentation of the advice, however, is critical. You must make it clear while maintaining a supportive, reassuring manner, that their smoking is unquestionably related to the symptom or incident. Only one way to avoid subsequent similar episodes is to quit. If a patient I’d like to quit, but I’ve tried three times, and nothing works,” say to them, for example, “The number of attempts that the average smoker needs to make before being successful in quitting is three or four. Learning any new skill or behavior takes time.” Such advice leaves the patient feeling hopeful instead of hopeless. How can I anticipate which patients will be able to quit?
A strong determinant of success in smoking cessation is the degree to which the smoker wants to stop. Another important determinant is the patient’s estimate of the difficulty of termination. Those who believe quitting will easy seem to suffer fewer withdrawal symptoms and enjoy longer-lasting success than those who view the task as impossible.
Generally speaking, the more facets to your intervention strategy, the more likely its success. If for example, you provide the patient with some basic advice, see the individual for a few follow-up visits, prescribe nicotine polacrilex, and refer the patient to group therapy or a clinic such as the American Lung Association’s Freedom from Smoking program; you may expect sustained abstinence rates of about 40%.
Which approach for which patient?
In deciding which approach to try, realize that about 46% of patients who stop smoking for at least one year do so without using a structured treatment program.* Most patients appear not to like to go to programs or clinics for special help.
Begin your selection process by asking the patient which method he or she thinks would work best. Talk about which methods he has tried in the past and what he thinks were the pros and cons of each. Then present new cessation options and educate the patient on what each involves. You may want to have someone in your office develop a list of cessation resources, including smoking-cessation groups and clinics, hypnotherapists, and support groups. Have this list available when presenting cessation options.
How can I keep track of which of my patients are smokers?
Studies suggest that many physicians do not talk to their patients consistently about their smoking habits and do not remind them often to quit. In one report, for example, only about 44% of smokers had ever been told by their physician to quit.* But those asked to stop were the heaviest smokers, had smoked for the longest time, and felt they would find quitting most difficult-precisely the type of patient whose chance of stopping is slimmest. Physicians’ advice alone may well fail under such conditions; many doctors, as would anyone else faced with repeated failure, then tend not to try as often or as hard at convincing their patients to quit smoking.
The heaviest smokers became the focus of cessation attempts in these studies partly because physicians have underestimated the number of smokers in their practice. Physicians also address primarily those problems their patients bring to their attention. If a patient’s problem is unrelated to smoking, the subject of quitting is not likely to be raised.
While a minute or two of your caring advice will boost abstinence rates, maximizing the success of smoking cessation in your practice requires more. The development of a comprehensive cessation program must involve part or all of your office staff and include a means of identifying all patients who smoke, provide ongoing documentation of their smoking history and current smoking behavior, and prevent recidivism by offering support after a successful quit. For an office program to be effective, someone must be put in charge, and each staff member must be trained in his or her particular role as well as in the overall workings and goals of the cessation program. Ensuring that your office is a smoke-free environment and having cessation-oriented posters and literature around also help to ensure success.
Having your nurse inquire about tobacco use should be as routine as taking the patient’s blood pressure, and the patient’s chart should be labeled accordingly. One dramatic approach is to place a black dot or another label on the charts of those patients who smoke and a gold star on the charts of those patients who don’t, although this may not be to every physician’s taste.
Ask the smokers how much they smoke and record the information on an index card, which will after that contain the patient’s smoking history and all pertinent information from discussions about smoking (see Figure 1). Record everything related to smoking cessation, including passing mentions of the topic, so that when the patient returns, you can say, for example, “I see from your card that six months ago you were considering quitting, but there was something stressful going on in your life that made you decide to wait. Has that passed, and are you ready to try now?” This approach emphasizes to the patient that smoking cessation is something important enough for you to have remembered what has said months ago and to have raised the issue again. It also makes it clear to the patient that you intend to raise the issue repeatedly.
The index card also serves to communicate to your staff what follow-up should ensue. If charts are not immediately accessible to your office system, it may be a good idea to keep these cards filed separately so they can be updated quickly if the patient calls with a new concern regarding cessation.
What should I say?
Help patients focus on individual cessation needs without worrying about the judgmental perceptions of a non-smoking physician. This is one area in which you do not need all the answers-only the questions and the patience to listen. Start by asking all smokers who come to your office how much they smoke, whether they have ever considered quitting, and which methods they may have tried. Because four out of Eve smokers have stopped smoking for some long or short period in the past, they usually have a repertoire of potentially successful and unsuccessful quitting behavior patterns.
Ascertain what problems were encountered in previous cessation attempts, and what caused the resumption of smoking. If the patient still wants to quit-really want to quit-discuss alternative strategies. A patient may be concerned about the health effects or feel like a social outcast because friends no longer smoke.
Determine whether the patient has noticed definite changes in health recently or if the concern is more abstract, based on statistics. If for example, the patient mentions that backpacking at 6,000 feet causes more huffing and puffing than ever before, the door is open for you; give praise for being observant as you assure the patient that loss in function is a consequence of smoking, and point out other smoking-related changes in your physical examination. An inveterate smoker needs only to look at or listen to his body to discover staining of the skin or teeth, smokers’ lines and crow’s feet on the face, a rapid pulse, elevated blood pressure, and pulmonary bronchi.
Are the adverse health effects of smoking reversible?
It is never too late for smokers of any age to take steps to improve health and quality of life. Let your patient know that many of the symptoms being felt are reversible and that the patient will usually feel better within one year of quitting.
It is important for patients to feel in control of their destiny, and one way to foster this sense is to encourage them to make a critical decision that will directly affect life span. Explain, by way of example, that a 30year-old who smokes two packs of cigarettes per day forfeits approximately nine years of life but can regain seven or eight of those years by quitting. Similarly, a 65-year-old who smokes two packs of cigarettes per day sacrifices about six years of projected life span, and can regain four of those years by kicking the habit altogether.
How can I support the patient’s effort or enforce the cessation attempt?
Doctor’s advice is important informing the patient. Assuming the patient wants to quit, the next step is to help the patient schedule a quit date. Consider using a contract to emphasize the gravity and finality of the undertaking (see Figure 2). Provide self-help literature, tell the patient that your secretary, receptionist, or nurse will call one week after the quit date to find out how the individual is doing, and, most important, offer all the support and encouragement you can.
Assure patients that you are interested in following their progress afterward and that you will be available to help them maintain cessation status. If patients feel they require more help, ask them to schedule an appointment with you or your office nurse for a counseling session.
Suggest that patients bring to the office counseling sessions a spouse, friend, or someone who lives with them who can support their efforts. Even when the spouse or living partner is a smoker, it may be important that that person agrees not to smoke near your patient or in their home. Also when the partner is a nonsmoker, instruct him or her to be constructively supportive, as nagging often contributes to failure. If your patient wants to engage in some other cessation strategy concurrently, such as rapid smoking or hypnotherapy, refer the patient to the appropriate local service provider unless, of course, you are skilled in these techniques yourself.
What long-term follow-up is appropriate for a patient who wants to quit smoking?
Even after a patient achieves initial success in stopping, continue recording on the index card, smoking status and other relevant information culled from cessation discussions as reinforcement to help prevent relapse. Schedule the first return office visit or telephone follow-up contact within 1-2 weeks. Every time you see or talk to one of your patients who has quit smoking, reinforce his behavior by praising his success.
If a patient resumes smoking, provide reassurance that smoking cessation is like any other new skill-several tries may be necessary before mastery is achieved-and calmly discuss where the attempted strategy failed. Ask if he would like to try again, perhaps with a different method.
Make it clear to your patient that if he slips and has one cigarette, it does not mean immediate readdiction or dependence. Emphasize that it must not be allowed to become habitual. Some people who have quit smoking on a regular basis smoke one or two cigarettes per month and can maintain that level; however, the high risk of complete relapse into chronic smoking accompanying such practice should be made clear. Check the status of such a minimal smoker at each office visit to ascertain that cigarette consumption is not slowly increasing, and ask if the patient wants to work on complete cessation; be sure to commend the patient on his accomplishment thus far.
Raising the issue of quitting each time you see the patient will not drive him from your practice. Most patients do not take offense if it is done in a friendly and supportive way, and, in fact, regard it as a positive sign that the physician is concerned with overall health rather than with only one aspect. Of course, how patients receive and interpret your reminders depends in large part on how you offer them.
What about the patient who does not want to quit smoking?
Eighty-five percent of all smokers want to stop. Most of the remaining 15% who say they do not want to stop is actually concerned that they will fail in their cessation attempt or that the benefits, such as relaxation, increased energy, or social acceptance, outweigh the costs. Ask the patient what he thinks is gained by smoking, and work with the patient to determine how those benefits might be derived from alternative means. If a patient insists he does not want to quit despite your advice, you must respect his wishes. People’s decisions, however, do change, and you should check again with the reluctant patient at each office visit.
How can I help my patient cope with the common withdrawal symptoms?
While the clinical course of withdrawal from nicotine addiction varies greatly among individuals, symptoms are most severe 2-4 days after that last cigarette. The symptoms slowly ease up during the following week but reach a second peak about ten days after quitting before slowly tapering off permanently. While simply craving cigarettes are probably the most common problem, people also frequently complain of irritability’, difficulty concentrating, gastrointestinal symptoms, and weight gain.
The most important factor in helping a patient cope with withdrawal emphasizes that the symptoms will be short-lived and can often be countered by planning for them. This is one reason why designating a definite quit date is so important; it allows the patient time to prepare. For example, if a patient anticipates that irritability will be a problem, suggest negotiating an arrangement with his living mate to provide distractions or to help keep stress to a minimum.
Your patient should consider initiating an exercise program. Not only does the exercise help to prevent weight gain, but it provides relaxation and distracts the patient from thinking about cigarettes. Suggest that the person devotes the time formerly spent smoking to an exercise program. For example, a 15-20 minute walk might be an alternative to smoking the first cigarette of the day. You might also recommend relaxation techniques as complicated as biofeedback or as simple as deep breathing, depending on your perception of the person’s needs and personality.
Do all people who quit smoking gain weight?
Yes, most do, although not much. To many, the fear of even 5 extra pounds is more than enough to deter them from quitting. Acknowledge patients’ concerns about weight gain without brushing them off with “Don’t worry about it.” Reassure patients that the weight gain almost never exceeds 510 pounds, and that very few ex-smokers maintain the added weight for more than one year. Suggest that patients monitor what they eat, keep carrot and celery sticks on hand, and exercise regularly, and reassure them that if they do gain weight, you will work with them to design a weight-loss program.
It was believed that ex-smokers put on weight solely because increased food intake compensated for the lack of oral gratification formerly provided by the cigarettes. That is not entirely accurate. E x-smokers are likely to gain some weight regardless of whether they increase caloric consumption or not. Nicotine appears to speed metabolism; when it is withdrawn, metabolism slows. Why do some patients with respiratory disease feel that symptoms worsen when they stop smoking?
Once a person no longer breathes in smoke, the respiratory cilia begin working again. The patient’s perception that there seems to be more mucus and pulmonary debris is correct. While it may be annoying, phlegm production is a good sign, and will usually subside within 2-3 weeks.
What other physiologic changes take place once people quit smoking?
The data are not clear about the effects of cessation on blood pressure because blood pressure evaluation and interpretation are confounded by so many other factors. Generally, heart rate and diastolic blood pressure decrease slightly-sometimes as soon as six hours after quitting-but if a patient gains weight, of course, blood pressure may then increase.
Circulating levels of epinephrine, norepinephrine, and catecholamines decrease immediately following cessation. EEGs performed during the immediate cessation period show decreased cortical arousal, which correlates with the concentration difficulties so many quitters express. There is a linear relationship between serum nicotine level and beta-endorphin levels, which may be partly responsible for the difficulty many have in overcoming nicotine addiction.
Is reduction or switching to low-tar brands an effective avenue toward cessation, or just a smoke screen?
It is a rare person who cuts down, say from one pack to a half of a pack per day, and remains at that level or quits. Almost all such smokers will eventually work themselves back up to, or beyond-the number previously smoked.
Both cutting down the number of cigarettes smoked and changed to low-tar brands have been shown to be ineffective as long-term strategies. Mostly because smokers of cigarettes, pipes, cigars, and users of snuff will unconsciously compensate for diminished nicotine intake in an attempt to maintain serum nicotine levels. Such behavioral compensations include taking longer drags, smoking cigarettes down to the filter, or holding the smoke in their lungs for longer periods.
For most smokers, the “comfort level” derived from smoking corresponds to a serum nicotine level of 20-30 ng/mL. If smokers do reduce the number of cigarettes smoked, it is important that you instruct them on how to change their inhalation patterns. This will help them to reduce nicotine dependency and intake. For patients who are serious about their intention to quit, cutting down is usually not the most successful approach. Although it may be helpful during the weeks that lead up to the official quit date.