Tc obacco Use Stephen F. Rothemich Tobacco use remains the leading cause of preventable death in the United States, a rank that it has held ever since deaths were first quantified by risk factors in the early 1990s(1, 2). In the United States, cigarette smoking and exposure to tobacco smoke account for approximately one in five deaths (438,000 people)each year, as well as 5.5 million years of potential life lost(3) Although overweight(the product of a combination of poor diet and physica inactivity) runs a close second as a leading cause, tobacco use causes more than twice as many deaths as alcohol consumption, motor vehicle accidents firearm use, unsafe sexual behavior, and illicit drug use combined. In addition to this staggering loss of life as of 2001 tobacco use cost society more than $167 billion per year through smoking-attributable health care expenditures ($76 billion)and adult productivity losses ($92 billion). Helping smokers quit is ranked by the National commission on Prevention Priorities as among the top three most effective and cost effective clinical preventive services that clinicians can offer patients (4) Smoking harms nearly every organ of the body, has been causally linked to dozens of adverse health effects(see Table 9.1), and reduces overall health status(5). Cigarette smoking alone is responsible for more than 30% of U.S cancer deaths(6). Smokeless tobacco use causes oral cancer and other ora lesions. Environmental tobacco smoke, a known human carcinogen, causes premature death and disease in children and in adults who do not smoke; scientific evidence indicates no risk-free level of exposure to secondhand smoke exists (7). Quitting smoking has both immediate and long-term benefits, reducing the risk of diseases caused by tobacco and improving health in general In 2004, 44.5 million Americans, or 20.9%0 of the adult population, smoked cigarettes; 23.4% of men smoked compared with 18.5% of women Among whites, 22. 2% smoked compared with 20.2% of blacks. The highest levels of smoking were among people aged 25-44 years(23.8%); American Indians and Alaskan Natives(33.4%); people who had earned a General Educational Development(GED) but not a standard high-school diploma (39.6%); and people living below the poverty threshold (29. 1%6)(8). Although 235
236SECT|ON‖!· WHAT TO DO WITH THE|NF○ RMATION TABLE 9. 1 Adverse Health Effects of Smoking Supported by Strong evidence Cance Bladder Cervical Esophageal Kid Leukemia L g Pancreatic Respiratory Effects Asthma(poor control) Asthma-related symptoms Chronic obstructive pulmonary disease Impaired lung gro ng function Respiratory symptoms(coughing, phlegm, wheezing, dyspnea) Cardiovascular Effe Abdominal aortic aneurysm Ath Cerebrovascular disease Coronary heart disease Reproductive Effects Low birth weigh Placental abruption Placenta previa Preterm birth Reduced fertility Sudden infant death syndrome
CHAPTER9·T○ BACCO∪SE237 TABLE 9. 1(Continued) Other Effe Cataract Hip fractures Increased absenteeism Increased health services usage Low bone density Peptic ulcer disease(Helicobacter pylori positive) Poor surgical outcomes Poor wound healin Adapted from U.S. Centers for Disease Control and Prevention. The health consequences of smoking report of the surgeon general. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2004: 2-6 the national smoking rate is slowly declining, it is still well above the national goals set in Healthy People 2010: less than 12% for adults and 16% for adolescents (9). This chapter provides clinicians and their associates with the necessary information to institute effective smoking cessation techniques in their practices. Although this chapter emphasizes smoking cessation, these interventions may be used to help smokeless tobacco users quit as well The interventions described are based on the u. S. Public Health Service (PHS) guidelines, with additional emphasis on the role of telephone"quit lines, now available in every state in the United States. Although one option for clinicians is to deliver intensive counseling as the primary focus of a series of clinic visits, an alternative is to offer simple advice to quit coupled with referral to a quit line, a 30-second option that many clinicians may find easier to incorporate into their daily practice. BACKGROUND Many clinicians recognize smoking as a major threat to a patient's health but do not feel confident in their ability to intervene effectively. Most clinicians have not experienced success in helping paticnts to stop smoking.Most have treated patients with significant tobacco-related diseases who have been unable to stop despite multiple attempts, even as they became sicker. Repeated failures to help patients stop smoking frequently cause clinicians to become discouraged and reinforce the belief that nothing can be done
238SECT|○N‖· WHAT TO DO V| TH THE|NF○RMAT|ON about smoking. Another barrier preventing clinicians from trying to help patients quit smoking includes a lack of formal training in tested cessation techniques. Perhaps most important, many office practices are not organized to support the delivery of smoking cessation interventions However, the evidence is clear: advice from clinicians helps smokers quit. Even providing brief, simple advice increases the likelihood that a smoker will successfully quit and remain abstinent 12 months later(10). The methods outlined here show how best to use the limited time available to impact smoking behavior among patients METHODS Treating Tobacco Use and Dependence, which is available online in its entirety(11)and in a summary for clinicians(12), details the PhS clinical practice guidelines for promoting smoking cessation among patients Clinician Intervention The clinician intervention recommended in the phs guideline comprises five activities, each beginning with the letter"A"(often referred to as the 5 As, as discussed in Chapter 5) Ask all patients about smok Advise smokers to stop Assess if the smoker is willing to make a quit attempt Assist their efforts with self-help materials, a quit date, and possibl cessation medication Arrange follow-up This intervention plan describes a general approach to patients who smoke and can be used in almost any outpatient encounter, whether th clinician and patient have 30 seconds or 30 minutes for the discussion (13/ c Ask about smoking at every opportunity. For example, a nurse or other staff member should routinely ask patients“ Do you smoke?”or“ re you still smoking?"at each visit, usually while measuring vital signs. Once it is known that a person smokes, an identifier should be placed prominently on the patient's chart to remind the clinician and staff to discuss smoking at each visit (see Fig 9. 1).(See Chapters 21 and 22 for further information about chart alert stickers, automated prompts, and other clinician reminder systems. )Patients who have never smoked or who formerly smoked should be congratulated on their decision Advise all smokers to stop. A clear statement of advice(e. g, "As your physician, I must advise you to stop smoking now)is essential. Many patients do not recall receiving this advice from their clinician. Therefore, the statement must be
CHAPTER9. TOBACCO USE 239 Tobacco use:(circle one) ret)→ Advised to quit Former Ready to M quit in next Never 30days?□N Figure 9.1. A tobacco-use "vital sign"stamp, which can appear prominently on the patient's chart where vital signs are recorded to remind the clinician and staff to systematically assess smoking status at each visit. The traditional version, illustrated in the U.S. Public Health Service guideline(12), only contains the information in the left-most column of the version shown here(the first of the 5 As, "Ask"). This second generation stamp,courtesy of Stephen F. Rothemich, MD, MS, is designed for also obtaining and documenting the second and third as(“ Advise”and“ Assess”). short, clear, and memorable. Personalization of the message by referring to the patient's clinical condition or family history may add to the effectiveness of the advice. The type of motivation that will help smokers quit varies greatl from patient to patient. Although almost any clinical encounter provides an opportunity to discuss smoking, timing of the advice can be very important The so-called teachable moment is that time when a patient's circumstances make him or her more receptive to advice. Teachable moments occur when patients are affected by diseases caused by smoking, but they may also occur following auscultation or pulmonary function testing, or when a friend or relative is Assess if the smoker is willing to make a quit attempt. Patients'level ofinterest in stopping smoking is usually evident in discussions with the clinician. Ifit is not, ask patients if they want to stop. See Chapter 5 for further information about the transtheoretical model and stages of readiness to change, which includ precontemplation, contemplation, preparation, action, and maintenance(see pages 132-133) Patients not ready to make a quit attempt (precontemplation or contemplation stages)may respond to a motivational intervention. Th clinician can motivate patients to consider a quit attempt with the 5 Rs Relevance- encourage the patient to indicate why quitting is personally relevant Risks-ask the patient to identify potential negative consequences of tobacco use Rewards--ask the patient to identify potential benefits of stopping tobacco Roadblocks--ask the patient to identify barriers or impediments to quitting Repetition--repeat motivational intervention at every clinic visit
240SECT|ON‖· WHAT TO DO WITH THE INFORMAT○N Assist the patient in stopping. For those patients who express a sincere desire to stop smoking, the clinician should help them set a specific date for the next attempt. There is evidence that patients who set a "quit date are more likely to make a serious attempt to stop than those who do not(14). This date should be in the near future(generally within 4 weeks), but not immediate, giving the patient the necessary time to prepare to stop. Patients should b encouraged to announce their"quit date "to family, friends, and coworkers Once a patient has selected a specific date to stop, information must be provided so that he or she can prepare for that date. For patients who can read, this is easily accomplished by providing them with a self-help brochure. Effcctive brochures provide the patient with necessary information about smoking cessation(e. g, symptoms and time course of withdrawal,cessation tips, reasons to quit, answers to common questions). A list of print and online patient education materials is provided later in the"Resources-Patient Education Materials"section at the end of this chapter. Patients who cannot read need to acquire this information from other sources, such as audiotapes, video materials, or counseling by a clinician or health educator. Arrange follow-up visits. When patients know that their progress will be reviewed, their chances of successfully stopping improve. This monitoring may include a letter or telephone call from the office staff just before the quit date, reinforcing the decision to stop. Most relapses occur in the first weeks after cessation. A person who comes to the office after being a nonsmoker for 1-2 weeks has a much improved chance of remaining abstinent than those without follow-up (15). For this reason, it is critical that patients be contacted during their first 2 weeks of abstinence to reinforce their decision to stop Nurses or other clinicians as well as the physician may conduct this follow-up in the office or by telephone. It should consist of an assessment of the patient's progress, troubleshooting for any problems encountered or anticipated, and discussion of the effectiveness or side effects of cessation medications Although follow-up visits are critical during the first 2 weeks after cessation, clinic staff should remain in contact with the patient and schedule a formal follow-up visit in 1-2 months. For patients who cannot return for an appointment, contact by telephone or by mail may be helpful. Many patients can benefit from the social support and information offered through quit lines, Internet discussion sites, and local support group sessions offered y the American Cancer Society, the American Lung Association, or local churches or community organizations(see page 250). While onl ma proportion of patients referred to such programs actually participate(16), these programs have the potential for large public health impact. However, for individual patients, clinicians should consider these referrals as augmenting not replacing, a clinician's care
CHAPTER 9. TOBACCO USE 241 Patients may also express interest in techniques such as hypnosis and acupuncture. These have not been proved to be effective through randomized, controlled trials but are probably not harmful. Informed patients who wish to try these techniques should not be discouraged from doin g Pharmacologic Agents Clinicians should consider recommending over-the-counter nicotine replacement therapy or one of several prescription medications that can increase the success rate for quit attempts. Table 9.2 summarizes currentl available pharmacologic adjuvants for smoking cessation. U.S. Food ane Drug Administration(FDA)-approved pharmacotherapies recommended as first-line agents include bupropion, varenicline tartrate, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine patch, and nicotine lozenges Secondary pharmacotherapy options, not FDA-approved for use in smoking cessation but of proven benefit, include nortriptyline and oral clonidine(17, 18). A nicotine vaccine, which will prevent transfer of nicotine through the blood-brain barrier, is in early development Selection of an appropriate agent depends on patient contraindications, patient preference, cost/coverage issues, and clinician familiarity with the pharmacotherapy. Among over-the-counter options, patches offer simplicity, while lozenges or gum give patients more control over dosing schedules. All forms of nicotine replacement therapy can help patients stop smoking, almost doubling long-term success rates(19), with similar efficacy to prescription medication. The long-term use of nicotine replacement therapies does not pose a known health risk and may be helpful with smokers who report persistent withdrawal symptoms. However, use of any nicotine replacement therapy should be avoided for 1 month following myocardial infarction serious arrhythmia, or unstable angina Clinical trial data suggest that bupropion and varenicline tartrate are effective aids to smoking cessation. Bupropion can be paired safely with nicotine replacement therapy, although blood pressure may need more careful monitoring. Even when used alone, bupropion use leads to quit rates about double those achieved with the nicotine patch. The effects of bupropion go beyond antidepressant activity, but its mechanism of action in smoking cessation remains unknown. Additionally, the FDA has approved the use of bupropion sustained release for long-term maintenance. The more recently approved varenicline tartrate appears to be even more effective than ropE on Nortriptyline and clonidine have smoking cessation efficacy, and while these may produce a number of unpleasant side effects, they should be considered when FDA-approved medications are not available to patients due to cost issues
242SECT|○N‖· WHAT TO D○W| TH THE| NFORMAT|ON TABLE 9.2 Pharmacologic Adjuvants for Smoking Cessation Agent( Brands)Advantages Disadvantages IcotIne OTC Proper use required gum Flexible dosing Frequent use required Nicorette) Fast nicotine delivery No food or drink 15 min May delay weight gain before use Possible jaw pain, mouth soreness,dyspepsia, h CUps A void use with dental roblems or temporomandibular joint syndrome cotone OTC Frequent dosing required lozenge Flexible dosing No food or drink 15 min (Commit Fast nicotine delivery before use Possible mouth soreness, OTC Slow nicotine delivery patch Different strengths available Less flexible dosing (Habitrol Daily application Possible skin irritations Nicoderm Overnight use may reduce Possible sleep problems if CQ early morning cravings worn at night Nicotrol) Nicotine Fastest nicotine delivery Frequent dosing required nasal spray Reduces cravings in minutes Possible nasal and eye (Nicotrol Flexible dosing Irritation, coug Most addictive nicotine replacement therapy Nicotine Flexible dosing Frequent dosing required nhal Mimics hand-to-mouth Possible mouth and throat (Nicotrol routine of smoking Irritation inhaler) Bupropion Non-nicotine Possible insomnia, dry mouth, SR Easy use headache, tremors, nausea (Wellbutrin May be combined with anxiety SR, Zyban) nicotine replacement therapy Avoid use with seizure May delay weight gai In disorders bulimia, anorexia May be effective in depression(see Chapter 13)trauma, current use of bupropion or a monoamine hibi
CHAPTER 9. TOBACCO USE 243 TABLE 9.2( Continued) Agent(Brands) Advantages Disadvantages Varenicline Easy use Possible headache, vomiting, tartrate May ease withdrawa fatulence insomnia, abnormal (Chantrix) symptoms dreams, dysgeusia(taste May block effects of disturbance) May delay weight gain May be effective in depression(see Chapter 13) Nortriptyline Easy use Not FDA approved for (Aventyl Inexpensive smoking cessation HCI May be effective in Possible tremor, headache, dry Pamelor) depression(see Chapter 13)mouth, nausea, indigestion constipation, diarrhea, fatiguc weakness, anxiety, insomnia Avoid use with alcohol methyprylon, or monoamine oxidase inhibitor Clonidine Easy use Not FDa approved for oral expensive moking cessation (Catapres) Possible dizziness, weight gain, drowsiness, dry mouth, constipation Avoid use with alcohol OTC=over-the-counter; FDA= U.S. Food and Drug Administration. Quit Lin The use of telephone-based tobacco cessation services, commonly known as quit lines, has been shown to improve smoking cessation rates(20) Their effectiveness with smokers who use them is well established. In many states with comprehensive tobacco control programs, quit lines play an important role in media-based efforts to encourage smoking cessation Depending on the state, and sometimes by insurance status within states, quit lines offer either reactive counseling(smokers can call as needed during their quit attempt)or the more effective proactive counseling(a series of counseling calls initiated by quit line personnel timed around a qu attempt)(21). Quit lines are accessible and eliminate many barriers associated with traditional smoking cessation classes or support groups. These include having to wait for sessions to be offered, needing to arrange transportation
244SECT|ON‖· WHAT TO DO WITH THE INFORMATI○N and/or childcare, and discomfort with participating in a group discussion. Patients underrepresented in traditional cessation services, such as smokers of ethnic minority back grounds, actively seek help from quit lines(22) Every quit line serves thousands of tobacco users each year, a volume rarel achieved by other behavioral services, yet they currently reach only. 1-5%6 of the tobacco users in their states each year Practices can extend their capability of providing intensive counseling by encouraging patients to utilize a quit line. One way to do this after offering brief advice to quit is simply to provide the national toll-free number (1-800-QUIT-NOW) that automatically routes callers to their state's quit line and to recommend that patients call (reactive telephone counseling). This can be done in 30 seconds. When incorporating all the 5As into busy office visits shortcut and far better than not addressing tobacco use at al very reasonable is not feasible, this"Ask, Advise, and Refer"strategy(22)is a In some states clinicians can send referrals directly to the quit line, whose counselors will then contact the patient directly (proactive telephone counseling). Proactive counseling, which eliminates the need for the patient to place the call and has been proved to be more effective than reactive counseling(20), is usually arranged by completing a referral form(often signed by both patient and clinician), which is then faxed to the service. Most state quit lines offer proactive counseling only to smokers ready to make a quit attempt in the next 30 days (preparation stage of the transtheoretical model, see page 132 in Chapter 5), and practices may therefore need to screen potential quit line referrals to verify their stage of readiness to change. For smokers not yet ready to quit, providing the telephone number for them to call is more appropriate. In either case, clinicians should be prepared to respond to calls from patients who are referred to quit lines and want prescription-only cessation medication options that were not discussed and arranged before their referral COMMON PROBLEMS AND POSSIBLE SOLUTIONS Weight Gain The issue of potential weight gain is important for many patients who try to stop smoking. Some patients cite weight gain as the reason for relapse after previous attempts to stop The average amount of weight gained after cessation is approximately 5 lb. Some patients gain no weight after cessation, but a small proportion of people gain large amounts of weight There are several obvious recommendations that can be made to patients concerned about preventing weight gain. Attention to caloric intake can be as simple as monitoring portion size, making healthy food choices, and
