Smoking Cessation

Abstract

Smoking prevalence rates have substantially decreased among both adults and adolescents in the past 15 years. The decreasing rates are largely because of the effectiveness of tobacco control initiatives, including bans on smoking, increases in tobacco taxes, and behavioral interventions; yet a minority of people continue to smoke. It is possible that these individuals may be more resistant than others to smoking cessation interventions. As a result, it is important to intervene systematically. Brief advice offered in a primary care setting is well established as an effective strategy to promote smoking cessation. Barriers to providing smoking cessation in a primary care setting are discussed, and methods to enhance these efforts through consistent screening for tobacco use, use of motivational techniques, brief follow-up after quit attempts, and use of pharmacotherapy are provided.

‘. . . current smokers may have certain cognitive processes or coping mechanisms that make them less susceptible to the social unacceptability of smoking . . .’

More than 20 000 genes are potentially resistant to antibiotics. ¹ Although antibiotics revolutionized medicine and saved countless lives, their use has created some strains that are immune to their effects, threatening a return to a pre–antibiotic-like era. ² The development of resistance or tolerance occurs from the first time that a therapy is employed, and resistance has been clearly shown to occur in the treatment of viral, parasitic, fungal, and bacterial infections. ² It is also possible that a form of “behavioral resistance” occurs when lifestyle interventions are employed. There are potential parallels to antibiotic resistance and the resistance that we may see at a behavioral level.

Cigarette smoking has become socially unacceptable in the United States, largely because of tobacco control initiatives such as smoking bans in the workplace and aggressive mass media campaigns. ³ Along with other public health strategies, the increased social unacceptability has contributed to significant reductions in cigarette smoking among adults and youth. ³ A little more than 15 years ago, a quarter of US adults were smokers, while recent estimates indicate that only 18% of adults reported tobacco use in 2012. ⁴ During this same time frame, the prevalence of smoking among high school seniors declined from 25% in 1997 to 9% in 2013. ⁵ The continued use of tobacco control initiatives, including bans on smoking in the work place, tobacco tax increases, mass media campaigns, and behavioral interventions, could mean that the people who continue to smoke or become smokers in the face of these measures may be more resistant to change. Specifically, current smokers may have certain cognitive processes or coping mechanisms that make them less susceptible to the social unacceptability of smoking and other anti–tobacco use strategies. With this in mind, it is important to intervene systematically. As discussed in this issue by Ciccolo and Busch, ⁶ there is strong support for behavioral smoking cessation interventions. The following addresses common barriers to providing smoking cessation advice in a primary care setting and methods to enhance the effectiveness of advice provided given that influencing patient’s smoking-related behaviors may be more difficult than ever.

Providing Smoking Cessation Advice in Primary Care Is Effective

Overall, the effectiveness of brief advice from health care providers (HCPs) to promote smoking cessation in patients is well established. ⁷ HCPs who provide brief counseling to smokers increase the likelihood that their patients quit by 1% to 3%. ⁷ It is estimated that 70% of smokers see a primary care provider yearly, making primary care visits an ideal structure through which to reach smokers. ⁸ Though the relative impact of providing smoking cessation counseling may seem small, intervening in a primary care setting has the potential to make a substantial impact from a public health perspective. ⁹

Several barriers exist to providing smoking cessation advice in a primary care setting. For example, there is a perception that providing smoking cessation counseling is ineffective,^10,11 patients are unmotivated,^12,13 physicians feel they lack the training,^14,15 and there is a lack of time to provide counseling in a typical visit.^13,16 Furthermore, it may seem that providing advice to patients who are not ready to make a quit attempt is a poor use of time, especially when patients are presenting with primary complaints unrelated to tobacco use. ¹⁷

Addressing the Lack of Time and Training

While several behavior change theories have been used to conceptualize patients’ motivation to quit smoking, the transtheoretical model has remained popular, greatly influencing the development of the guidelines for clinical practice and forming the basis for many smoking cessation interventions.^18,19 The transtheoretical model is a behavior change model that suggests that smokers progress linearly through a series of stages of readiness for change, sometimes repeatedly, before successfully quitting. There is an assumption that mismatched interventions may be counterproductive and a waste of resources (eg, time). ¹⁹ As a result, physicians should continually assess an individual’s stage of change and tailor the intervention accordingly, with the goal being to help the patient progress to the next stage and ultimately abstinence. ²⁰

One reason that HCPs feel unprepared to provide smoking cessation advice maybe the popularity of stage-based models that continually reassess their patients’ motivation to continue smoking and/or to quit at each visit and appropriately tailor advice to their particular stage of change. This process can seem overly complicated and time consuming to conduct regularly at every office visit. However, there is evidence to suggest that continually assessing stage of change and tailoring advice to an individual’s stage is unnecessary. ¹⁹ A recent Cochrane review ¹⁹ concluded that stage-based interventions are no more effective than non–stage-based interventions at promoting a quit attempt, suggesting that physicians need not dedicate resources to assessing stage of change and attempting to tailor interventions to match the patient’s specific stage. ²¹ The validity of the thranstheoretical model is further called into question by several studies that have reported that the majority of quit attempts are actually unplanned, and unplanned quit attempts are more likely to be successful at 6 months after the quit attempt than planned quit attempts.^19,22-24

Taken together, while there is a lack of evidence for the need to tailor advice to an individual’s stage of change, the fact that most successful quit attempts are unplanned underscores the fact that it currently is very difficult to predict when a smoker will be ready to make a successful quit attempt. These findings highlight the importance of assessing for tobacco use at every primary care visit and providing practical advice to quit smoking regardless of a patient’s motivation to change.

Enhancing the Effectiveness of Smoking Cessation Advice in Primary Care

Identification of Tobacco Use

One of the barriers to providing smoking cessation counseling in primary care is the failure to identify patients who smoke or who have recently quit smoking. ¹⁸ One way to address this issue is to create an office-wide system to inquire about smoking status at every visit. ¹⁸ For new patients this may involve including questions about current and previous tobacco use as part of a new patient medical history form to be completed by patients in the waiting room prior to their visit. Because tobacco dependence is a chronic illness that is very difficult to overcome, most patients who attempt to quit repeatedly cycle through periods of abstinence, relapse, and remission. ¹⁸ As a result, it is important to assess for tobacco use at every visit. Many physicians ask patients to complete a brief screener to identify any new symptoms or problems since their previous visit. Including a question in this brief screener about tobacco use (current, former, never) is a simple way to inquire about smoking status at every visit. Another method could be to have nurses ask about smoking status while taking vitals. Tobacco use or history of tobacco use can then be identified, and a prompt can be given to address tobacco use during the visit. ¹⁸ Developing a system that ensures tobacco use is assessed at every visit is a critical step in the provision of successful smoking cessation counseling.

Motivational Techniques

While there is a lack of support for the need to tailor advice to a patient’s stage of change, ¹⁹ the use of motivation techniques by HCPs appear to enhance the effectiveness of brief advice offered as part of a primary care visit. ²⁵ As discussed by Ciccolo and Busch ⁶ in this issue, the 5 Rs framework has been shown to increase quit attempts. ²⁶ The 5 Rs stand for Relevance, Risks, Rewards, Roadblocks, and Repetition.

• Relevance: HCPs should assist the patient with identifying personally relevant reasons to stop smoking, such as personal disease status or risk, pregnancy, children in the home, avoidance of the stigma associated with smoking, and so on. ¹⁸ The more personally relevant these reasons are, the more motivational they are likely to be.

• Risks: To facilitate evaluation risk, HCPs should ask the patient to identify known risks including acute, long-term, and environmental risks and then assist the patient with pinpointing the risks most relevant to them. The use of spirometry to measure lung age may be one way to provide concrete feedback to patients regarding their level of risk and functional impairment due to smoking. ²⁷

• Rewards: Assessing rewards involves asking the patient to identify the benefits of quitting smoking such as improved health, improved performance in physical activity, saving money, and providing a healthier environment for children. ¹⁸

• Roadblocks: HCPs should also ask patients to identify potential obstacles or roadblocks to a successful quit attempt. Common obstacles include lack of social support, weight gain, and withdrawal. HCPs can assist patients with developing strategies to deal with potential obstacles such as referral for additional counseling or recommending effective pharmacotherapy. The use of nicotine replacement therapy and other pharmacotherapies has been shown to significantly increase quit rates.^7,28,29

• Repetition: Finally, the importance of repetition of motivational techniques is critical due to the malleability of a patient’s motivation to change and the fact that it is unpredictable when a patient will be willing to initiate a quit attempt.

Promoting Adherence to Quit Attempts

Brief follow-up is recommended for patients who indicate that they plan to quit or have recently initiated a quit attempt. ¹⁸ Patients should be contacted on their quit date and at least 4 times following a quit attempt. This additional contact outside of an office visit not only increases perceived social support but also instills a sense of accountability. As previously mentioned, counseling and pharmacotherapies have also been shown to be effective in promoting adherence to quit attempts.

Conclusion

Tobacco dependence is a chronic illness that is very difficult to overcome. ¹⁸ Most patients who attempt to quit repeatedly cycle through periods of abstinence, relapse, and remission. ¹⁸ Given that smoking rates have substantially decreased in the past 15 years among adolescents and adults, it is possible that current smokers who are inundated by tobacco control initiatives may be more resistant to change. Historically, there has been a debate over the appropriateness of addressing smoking cessation in a primary care setting, ⁹ largely because of the difficulty associated with identifying smokers and the fact that many HCPs refrained from addressing smoking behaviors with patients possibly because of lack of training and time. ³⁰ Despite the difficulty associated with addressing tobacco use in a primary care setting, there is strong evidence to suggest that brief counseling or advice from HCPs is effective in promoting smoking cessation and is an important method through which to reach resistant to change individuals. Overall, advice to quit smoking delivered by HCPs can be enhanced by screening for tobacco use at all visits, the use of motivational techniques, brief follow-up after quit attempts, and the use of pharmacotherapy.