American College of Physicians: Internal Medicine — Doctors for Adults ®

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When it comes to smoking cessation, more is better

From counseling to combination therapies, sustained engagement and education can break a ferocious habit

From the June ACP Observer, copyright 2004 by the American College of Physicians.

By Deborah Gesensway

NEW ORLEANS—To get patients to quit smoking, the evidence suggests that physicians should follow one simple rule: the more, the better.

"You get more results with more effort," said William C. Bailey, FACP, a pulmonologist, professor of medicine and director of the University of Alabama Lung Health Center in Birmingham, Ala.

Studies have consistently shown "a dose response" in smoking cessation efforts, he pointed out. At his Annual Session presentation, "Smoking Cessation: Proven Methods to Help Your Patients Stop Smoking," he suggested that internists will see a payoff if they make a strong effort to throw every service—from medication to counseling—at smoking patients who want to quit.

Don't nag

If a patient isn't interested in quitting, Dr. Bailey cautioned against "nagging." While he recommended that doctors refrain from wasting time trying to change these patients' minds, he pointed out that you won't know which patients fall into this group unless you ask them at every visit.

About 30% of smoking patients will tell you they don't want to quit. Nonetheless, he said, internists should understand that the 2000 U.S. Public Health Service (PHS) guideline, which is based on grade A evidence, concludes that simply stating directly and unequivocally, "You need to quit smoking," will prompt 5% of people to quit. That direct statement works even better, he said, if you can personalize it, along the lines of, "Your asthma will improve if you quit."

A 5% success rate "might be considered a 95% failure rate," he said, "but just with that one statement repeated at every patient encounter, we could have a huge impact."

And although most primary care physicians might think they are already following the PHS guideline and asking patients about smoking at every visit, a 2001 study published in the Journal of Family Practice found that tobacco was discussed in only 21% of physician-patient encounters. That discussion was much more common, Dr. Bailey said, in practices that had standardized forms for recording smoking status.

The 5 A's: Ask, Advise, Assess, Assist, Arrange

After you ask patients about their smoking status, advise smoking patients to quit and assess that they are ready, Dr. Bailey said, the next stop is to assist them in quitting.

The first step is to arrange a quit date, preferably two weeks in the future. The reason for that delay, he said, is to give patients a chance to get ready to quit. They need time to throw away all tobacco products in their house, office and cars.

They also need time to tell family members and friends, so they will have the necessary emotional support. And there is a medical reason for a delayed quit date, Dr. Bailey said, which involves the drug bupropion (Zyban).

Bupropion reduces cravings, he said, but it has to be started one to two weeks before the quit date to work.

Because he strongly believes that the more you do for patients trying to quit, the greater the likelihood of success, Dr. Bailey said that in addition to prescribing bupropion, he also recommends nicotine replacement therapy to his patients. That includes gum, lozenge or patch for steady dosing, and a nasal spray or inhaler for times when the patient needs an extra dose.

"They aren't approved that way, but most physicians prescribe them in combination depending on the patient's need," he said. In fact, he said, nicotine replacement is more effective in combination than using one method alone.

One common mistake with using nicotine gum, he said, is that patients chew it continuously when it really is designed to be chewed only until it gets soft and then parked in the person's cheek, like chewing tobacco. Chewing and swallowing continuously, on the other hand, will make patients sick to their stomachs. "You need to clearly explain this to patients," he said.

Both bupropion and nicotine replacement should be tapered off and eventually discontinued after six months. If the patient relapses and wants to try quitting again, there is no problem with re-prescribing these drugs.

Understanding that relapse is a regular part of cessation is key, he said. The majority of relapses occurs during the first two weeks after quitting, he said, so it is essential for doctors to have regular follow-up visits with patients in the first week or two.

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