The United States Public Health Service (USPHS) Clinical Practice Guideline Treating Tobacco Use and Dependence
concluded that strong evidence supported the use of both behavioral and pharmacotherapeutic interventions for increasing tobacco abstinence rates. The USPHS recommended the use of two types of behavioral counseling which have been consistently shown to increase smoking abstinence rates: (1) providing practical counseling such as problem-solving, and skills training; (2) providing support during a smoker’s direct contact with a clinician.19
Tobacco dependence is best managed by treating it as a chronic disease: implementing systems to identify all people who smoke, providing brief treatment to all identified smokers, and arranging for more intensive interventions when needed.20
As with other chronic problems, relapse is the most likely outcome from any single treatment intervention. While some smokers may achieve long-term smoking abstinence (>6 months) after a single attempt, many others will try to quit multiple times and repeatedly relapse.22
Re-engagement of patients in the quitting process is critical. Medication adjustments and behavioral support should be provided until long-term abstinence is achieved. Frequent screening at follow-up visits and the offering of new medications can build confidence and reengage patients in treatment.
Identifying tobacco users
Establishing a systematic process to identify all tobacco users is critical. To increase the likelihood of addressing tobacco use, clinicians should have tobacco use status information available before they walk in the examination room. Providing advice to quit smoking increases success, and patients who are advised to quit report higher satisfaction with clinical encounters. Although many patients are asked about smoking and advised to quit, few patients receive assistance or referral to quit.24
Starting the conversation
Communicating about smoking during a health care visit can be challenging for providers and difficult for patients. Most general practitioners acknowledge that counseling smokers to quit is important and can be effective. However, providers are frequently concerned that their interventions may negatively impact patient satisfaction despite evidence to the contrary.25
In addition, providers may have a limited repertoire of counseling skills for addressing tobacco use with patients. Qualitative studies have found that there is a tendency by general practitioners to have discussions about stopping smoking only with patients who are motivated or to limit the discussions to health problems caused by smoking.26
Most smokers are ambivalent about stopping smoking despite knowing that smoking causes health problems. Many factors conflict with the desire to stop smoking. Patients anticipate the enjoyment from cigarettes that has been strongly paired with situations and stimuli that are present throughout their day-to-day activities. Withdrawal can be quite painful and relief from withdrawal can be very positively reinforcing. Patients may have concerns about loss of self esteem if a quit attempt fails, concerns about weight gain associated with quitting, and difficulty envisioning how they will manage to “fill the void” once they stop smoking.27
The combination of limited counseling repertoire among providers and the multiple reasons underlying patient ambivalence can decrease the likelihood that patients will talk with their providers about tobacco use and even inhibit patients’ reporting of tobacco related health symptoms.28
However, motivation to stop smoking can quickly change, and people who smoke can be helped to make a quit attempt despite being minimally motivated at first.29
Brief interventions adapted from Motivational Interviewing can help to engage a patient in a positive discussion about treatment options or prepare the patient to participate in more intensive treatment.31
One of the main barriers to engaging patients in an in-depth discussion of treatment options may be the difficulty in starting the conversation. A few simple questions can be effective for engaging identified smokers such as: (1) beginning with a non-judgmental open-ended question, (2) eliciting the patient’s self-perceived importance and confidence for stopping, and (3) assessing past quit attempts and treatment.32
A useful opening question is “What are your thoughts and feelings about stopping smoking?” This can assure the patient that the physician is interested in the patient’s perspective and provide useful information about a patient’s self-perceived obstacles to and benefits expected from quitting smoking. The motivation to stop smoking is a function of the self-assessed importance a patient places on quitting as well as their self-efficacy for succeeding. Scaling for importance and confidence can be used to elicit and strengthen a patient’s motivation to make a quit attempt and can be a function of the self-assessed importance placed upon quitting, and/or how successful the patient believes they will be if they try to quit. To assess both domains, providers can ask the following “scaling questions”: “On a scale of 0 to 10, with 0 being not important at all, how important it is for you to stop smoking?” and “On a scale of 0 to 10, with 0 being not being not confident at all, how confident are you in your ability to stop smoking?” The provider can then follow-up by asking the patient to elaborate from his or her perspective on why it is important to quit, and share what makes them feel confident they can succeed. The provider can then join the patient to discuss options for enhancing confidence by building future success on past success. Deciding on a plan of therapy can be facilitated by asking “What has helped you in the past to stop smoking for even brief periods of time?” If a patient is willing to make a quit attempt, sufficient treatment intensity should be applied to maximize the likelihood of success.
Incorporating behavioral counseling
A dose-response relationship exists between counseling time and tobacco dependence treatment outcomes.34
Many hospitals, health departments and health care facilities have hired or trained tobacco treatment specialists (TTS). More allied health professionals are becoming certified as tobacco treatment specialists (attud.org),35
and standards for providing evidence-based treatment are becoming recognized. TTS provide assurance to the referring clinician that the tobacco use intervention is consistent with evidence-based guidelines.
If a provider does not have local evidence-based tobacco treatment programs at his or her disposal, a telephone quitline can provide support. Each state in the United States, provinces in Canada, and jurisdictions in many other countries provide tobacco treatment counseling via the telephone. The simplest way for practitioners in the United States to engage patients in the tobacco quitline is to tell patients to call 1-800-QUITNOW after leaving the office. Through the National Network of Tobacco Cessation Quitlines, callers will be routed to the tobacco quitline in their state. States have differing levels of support that they can provide, and patients can receive this information when they call. Practitioners can also learn about the state-specific service offerings through the National Quitline Consortium website (naquitline.org).36
The Internet may also be effective in providing support to patients who are trying to quit smoking. A number of web sites have been developed to support quit attempts such as the American Legacy website “Become an Ex” (becomeanex.org) and Quitnet (quitnet.com). The US National Cancer Institute publishes “Clearing the Air,” a comprehensive guide to quitting smoking that is designed specifically for patient use. Smokers can order a free print copy of the guide or view it online (smokefree.gov).
Seven “first-line” pharmacotherapies are currently available for facilitating smoking cessation: five nicotine replacement therapies (ie patch, gum, lozenge, inhaler and nasal spray), bupropion sustained-release (SR) and varenicline. Clonidine and nortriptyline have been identified as “second-line” medications.19
“First-line” medications should be selected initially because of their well-reported efficacies and favorable side effect profiles.
All of the available pharmacotherapies indicated for the treatment of smoking cessation have been shown to be effective as monotherapy and are often used as such for light smokers (≤10 cigarettes per day). Our general approach at the Mayo Nicotine Dependence Center for moderate and heavy smokers (>10 cigarettes per day) is to prescribe the nicotine patch to provide continuous dosing and the ad libitum
nicotine replacement products (ie nicotine gum, nicotine nasal spray, nicotine inhaler, nicotine lozenge) to cover sudden urges and cravings. As a rough guide, the required patch dose (in milligrams) should be the same or slightly more than the number of cigarettes per day (cpd) smoked. For example, patients who smoke 30 cigarettes per day could be started on a nicotine patch dose of 35 mg/day (21 mg + 14 mg patches). We offer bupropion SR concomitantly if there are no contraindications. While combination therapy with multiple nicotine replacement therapies is not an FDA-approved treatment strategy, available evidence suggests that combination therapy increases smoking abstinence rates over monotherapy.37
Varenicline is appropriate for patients who have never tried any pharmacotherapy for smoking cessation and for those who have relapsed from abstinence using other medications. The recommended dosing for varenicline is 0.5 mg once daily for three days, twice daily for four days, then 1 mg twice daily for 11 weeks. Starter packs for the first month of therapy with the “ramp-up” are available in some locations. Patients should plan to quit on day 8 (Target Quit Day) of therapy, the point at which the target dose of varenicline is reached. We continue varenicline for 3 months beyond the initial 3 months if patients are at a self-identified risk for relapse.41
Interventions for smokers with comorbid COPD
Tobacco use interventions in patients with COPD have been demonstrated to be effective for increasing smoking abstinence rates. The LHS demonstrated that a combination of behavioral counseling and nicotine replacement therapy (NRT) was effective for promoting smoking cessation in COPD patients. In an 11-year follow-up of the LHS, 21.9% of participants in the smoking intervention group achieved long-term smoking abstinence compared to 6.0% of participants in the control group (P
Several other trials assessing the efficacy of pharmacotherapy for smoking cessation have been conducted in patients with COPD with mixed results. One study evaluated the efficacy of 12 weeks of bupropion SR for smoking cessation among 404 COPD patients. While bupropion SR increased smoking abstinence rates at 26 weeks compared to placebo (prolonged abstinence 16% vs 9%, P
< 0.05) no statistically significant difference in abstinence rates was observed between the two treatment groups at 12 months.42
In contrast, in a randomized trial of 370 patients with COPD randomized to NRT (sublingual tablet) or placebo, NRT significantly increased smoking abstinence rates at 12 months compared to placebo (biochemically confirmed 7-day point prevalence smoking abstinence: 17% vs 10%; odds ratio [OR]: 1.97; 95% CI: 1.06 to 3.67).44
In a study evaluating the comparative efficacy of bupropion SR and nortriptyline for smoking cessation, 255 subjects with COPD or at risk for COPD were randomized to bupropion SR (150 mg twice daily), nortriptyline (75 mg once daily) or placebo for 12 weeks. Among the subjects with COPD, 26-week prolonged smoking abstinence rates were highest in the bupropion group (27.3% vs 21.2% nortriptyline vs 8.3% placebo).45
The only statistically significant difference in abstinence was between bupropion SR and placebo (P