It's Not Users Who Fail -- It's Treatments That Don't Go Far Enough That Fail
Bad news surrounding tobacco use keeps coming: More disease and mortality are directly related to it, and this is not just for tobacco users -- secondhand smoke is more damaging than we have ever believed. Yet nearly a quarter of the population still smokes, and 3000 adolescents become users every day.
Some populations are at even higher risk for smoking-related comorbidities:
Racial and ethnic minorities -- higher mortality from smoking-related diseases (http://www.ahrq.gov/clinic/tobacco/racial.htm)
Hospitalized -- interferes with treatment, recovery, healing (http://www.ahrq.gov/clinic/tobacco/hospized.htm)
Psychiatric comorbidities or chemical dependencies -- greater use, stronger addictions, self-medicating (http://www.ahrq.gov:80/clinic/tobacco/comorb.htm)
Preadolescents and Adolescents -- easily addicted (http://www.youthtobaccocessation.org/ and http://www.ahrq.gov/clinic/tobacco/children.htm)
Elderly -- more complications, acute events, interferes with treatment (http://www.ahrq.gov:80/clinic/tobacco/older.htm)
Some good news.Over half of Americans who once smoked have quit. Currently there are more former than current smokers.
7 in 10 want to quit; 9 in 10 regret starting.
More is known about helping patients quit, more tools are available, more medications have been firmly established (doubling quit rates).
The tough news. Most have tried to quit, 2 in 5 will try again this year, but success rates are dismal -- without professional help.
Only 3 in 100 who try on their own are successful.
Many give up, not realizing that it takes several attempts.
Many never receive the optimal combination of counseling, medications, and support.
Challenge for clinicians. No primary care issue has such a combination of lethality and proven therapeutic options that are so widely neglected, yet we almost unanimously believe that it is our responsibility to help smokers quit.
Seven in 10 smokers see a healthcare provider at least once a year.
Most healthcare providers (86%) ask about tobacco and advise patients to quit. But all too often this is the only step that is taken.
Fewer than 1 in 3 recommend nicotine replacement therapy (NRT) or discuss counseling options or the importance of support; fewer than 1 in 4 provide educational materials, referrals, or follow-up. (http://www.americanlegacy.org/Files/Physicians_Study_-_Legacy_Report.pdf)
Even fewer adolescent smokers are counseled about quitting. (http://www.medscape.com/viewarticle/493447_4)
Why Not a More Active Role?
The biggest barriers are believing: (1) that smokers are "not motivated to quit" and (2) that cessation services are not reimbursable. (http://www.americanlegacy.org/Files/Physicians_Study_-_Legacy_Report.pdf)
But clinicians may also lack confidence due to lack of training:
1 in 3 are not confident assessing willingness to quit.
50% are not confident motivating smokers.
1 in 4 are not confident discussing treatment or prescribing medications.
2 in 3 are not confident monitoring progress, or making referrals. (http://www.americanlegacy.org/Files/Physicians_Study_-_Legacy_Report.pdf)
1. View tobacco use as a chronic, extremely addicting, relapsing disorder rather than a bad habit.
2. Communicate with patients about smoking:
Establish rapport -- avoid alienating, unrealistic goals, feelings of failure
Resistance develops when we don't listen, are too directive, pessimistic, or don't acknowledge difficulties
3. Go beyond simple advice -- dose response for both counseling and pharmacotherapy; more intense, better results.
4. Medications for most -- controller meds to stabilize brain chemistry; rescue meds for acute symptoms.
Controlling Agents Rescue Agents
Nicotine transdermal patch systems
Varenicline Nicotine gum (nicotine polacrilex)
Nicotine oral lozenge
Nicotine polacrilex oral puffer (vapor inhaler)
Nicotine polacrilex nasal spray
5. Individualize quit plans: match counseling and medications to each patient's needs.
6. Know insurance coverage for cessation services; push for greater coverage.
1 in 3 healthcare providers are not aware of coverage for counseling, 2 in 3 don't know about quitlines
7. Develop a referral network, especially for those with coexisting mental illness or other addictions.
2 in 5 healthcare providers have referrals for individual counselors, half for group programs
6 in 10 are not familiar with quitlines; 8 in 10 never refer to quitlines
3 in 4 not familiar with Web-based programs
8. Commit to monitoring and follow-up.
Only 1 in 4 healthcare providers "usually" monitor patients who are trying to quit; 1 in 10 never do
Prepare for Brief Tobacco Use Consult
Establish protocol for practice site:
Identify tobacco use as part of routine vital signs (http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm#Identification)
Document insurance coverage and coding for cessation services (http://www.ahrq.gov/clinic/tobacco/reimburs.htm and http://www.ahrq.gov/clinic/tobacco/codes.htm)
Pamphlets, brochures, and posters in waiting rooms (http://www.ahrq.gov/clinic/tobacco/order.htm)
Establish in-house counseling, staff member trained in tobacco counseling (http://www.americanlegacy.org/Files/Physicians_Study_-_Legacy_Report.pdf)
Establish follow-up schedule, referral network for local resources
ASK, ADVISE, ASSESS at every visit as per guidelines (http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm):
ASK about current use
Screen for depression, anxiety, alcohol abuse, if suspected
ADVISE quitting -- clear, strong, and tailored to personal issues
ASSESS interest in quitting -- "Are you willing to try to quit right now?"
Sharpen Counseling Skills
Open-ended questions and listen closely for patient "clues"
"Are you having any health consequences from smoking?"
"What do you like best about smoking?"
"What do you like least about it?"
"What would motivate you to quit?"
"Ever stopped smoking before? How many times, for how long, what were methods used?"
Associate use with current health issue -- a "teachable moment"
Impact on family members
"As your physician/clinician/healthcare provider, I must tell you that the most important thing you can do to improve your ___ is to stop smoking."
Help patients understand why they smoke -- write it down
Use the "Why do I smoke?" quiz (http://familydoctor.org/296.xml)
Interest in quitting: Think in terms of a process of increasing readiness and confidence to try; ask patients to rate their confidence to quit (using 1-10 scale)
If not ready or confident, focus on the "5 R's" (http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm#Willing)
If interested in quitting, develop quit plan according to guidelines (http://www.ahrq.gov/clinic/tobacco/tobaqrg.htm#Willing)
If not interested, use the 5 R's strategy to build motivation (http://www.ahrq.gov/clinic/tobacco/tobaqrg2.htm#Unwilling)
If Interested in Quitting:
Assess nicotine dependence (http://www.cancer.org/docroot/PED/content/PED_10_13x_Smoking_Habits_Quiz.asp?sitearea=PED):
"How many cigarettes do you smoke a day?"
"How soon after waking up in the morning do you have your first smoke?"
Elicit routines and rituals involving smoking (www.myclearhorizons.com)
Encourage to thinking about smoking with every cigarette: "Why do I want to do this?"
Provide suggestions for coping or facilitate problem-solving skills for triggers
Recommend/prescribe medications to break the addiction and to control symptoms (http://cancercontrol.cancer.gov/tcrb/Clearing_the_Air/symptoms.html)
Identify and recommend support -- family, friends, community groups, quit lines (http://www.smokefree.gov/quit-smoking/other_support.html)
Provide hand-outs to educate (http://misc.medscape.com/pi/editorial/cmecircle/2004/3607/pdf/tear_sheet.pdf)
Counsel at practice site or refer to local resources, counselors, specialists
Match patient to "best fit" in established referral network
Telephone Quitline -- minimal (1-800-QUITNOW)
Interactive Web site, if preferred over telephone: www.quitnet.com; www.trytostop.org/quitwizardV2
Local Group -- best choice if available and covered (especially high-risk groups)
Referral to local therapist -- if covered by insurance or patient has ability to pay
Mental health clinician -- if psychiatric or other dependencies
Hospitalized patients: Cochrane Review: http://www.cochrane.org/reviews/en/ab001837.html
Anticipate Additional Needs of High-Risk Patients
May have fewer resources and less support
May experience more relapses and have additional barriers to overcome
May need more intensive intervention -- both counseling and pharmacotherapy
More intensive team approach
If on-site counseling: return within a week of quit date; monthly visits until off medication
If referred, as necessary to monitor progress
Dealing With Resistance
Many excuses -- not ready, too hard, nothing works, too much else going on, etc.
Focus on the "5 R's":
RELEVANCE -- importance of quitting
RISKS -- consequences of not quitting
REWARDS -- benefits of quitting (www.nhlbi.nih.gov/hbp/prevent/q_smoke/top_ten.htm)
ROADBLOCKS -- managing barriers, eg, weight gain (http://win.niddk.nih.gov/publications/smoking.htm)
REPETITION -- repeat every visit until ready to try
Follow-up.Treat relapses positively: "We can use this to sharpen our plan for our next attempt; we're getting closer."
Remind patients that no one who starts smoking intends to become hooked -- that breaking the addiction will be one of the toughest, but also one of the most rewarding, things they will ever accomplish. Encourage them to picture the rewards -- feeling better, looking better, living longer, healthier family, saving money.
Also remind yourself that no task will bring greater rewards -- to individuals, families, society -- as increasing the quit rates of smoking patients.