Tobacco Cessation: Introduction
Cigarette smoking, which is responsible for over 400,000 deaths annually, represents the single most avoidable cause of premature death in the United States today. While the prevalence of smoking in the United States has declined over the past half century, about 40 million adults are current smokers ensuring that this behavior will continue to influence rates of premature morbidity and mortality rates for years to come. Most people begin smoking during their teenage years and struggle to quit as adults; smoking prevalence among adults is about 20%. Clinician needs to view nicotine dependence as a chronic health condition with exacerbations and remissions.
The best evidence on the benefits of smoking cessation comes from a 2007 systematic review by the International Agency for Research on Cancer which found that some of the benefits of smoking cessation occur shortly after quitting while other smoking-related risks are not moderated for months or years. An individual’s disease risk depends on previous duration and intensity of smoking, the presence of preexisting illnesses, and individual susceptibility. On a population-wide basis, it is now clear that progress achieved in extending life expectancy has been due in part to successful tobacco control, especially efforts to persuade and assist smokers to quit. There are benefits to quitting even among those who have already experienced health problems caused by smoking.
US Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004.
Most smokers report that they want to quit and approximately 40% attempt to stop smoking annually. Difficulty quitting is best predicted by how much one smokes on a daily basis and within 30 minutes of waking up each day, both of which are measures of nicotine dependence. However, most quit attempts are unplanned and usually only last a few days or weeks and are unsupported by the provision of pharmacotherapy and counseling support. Also, many smokers turn to methods with no proven efficacy (eg, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [other than nortriptyline], anxiolytics, benzodiazepines, β-blockers, silver acetate, mecamylamine, appetite suppressants, caffeine, ephedrine, St. John’s wort, dextrose tablets, lobeline, moclobemide [a monoamine oxidase inhibitor], acupuncture, hypnotherapy, or use of low tar cigarettes) further lowering quit success and contributing to a cycle of failed quit efforts that make the prospect of stopping smoking appear hopeless to many smokers. The reality is smoking should be thought of as a chronic relapsing problem with exacerbations and remissions.
In the United States, approximately 70% of smokers seek health care in any given year. Thus, health care professionals are in a unique position to treat tobacco dependence with counseling, provision of evidence-based drug treatments, and follow-up care.
Smoking cessation treatment often begins with a brief intervention, in which a physician or any other health care provider advises smokers to quit and may recommend methods for quitting. For many smokers, the only contact with the health care system may be through their family physician, and office visits often provide the impetus for smokers to attempt to stop smoking.
Meta-analyses report that brief counseling interventions have significant potential to reduce smoking rates, with even minimal brief interventions conferring an estimated 30% increased likelihood of cessation. A recent Cochrane review of brief smoking cessation advice from a physician compared with no advice (or usual care) identified a significant increase in the odds of quitting. Although previous studies have examined the effect of brief interventions in controlled settings, little research has been conducted to examine their effects in nonexperimental settings over an extended period of time.
A recent Cochrane review evaluating the effectiveness of brief smoking cessation advice from a physician found that advice from a physician compared with no advice (or usual care) significantly increased the odds of being smoke-free after 6 months and yielded an absolute difference of 2.5% in the rate of smoking cessation.
The Public Health Service (PHS) guidelines for treating tobacco use and dependence, last updated in 2008, continue to recommend that health care workers screen all patients for tobacco use and provide advice and follow-up behavioral treatments to all tobacco users. Current users are advised to quit; those who are willing to make a quit attempt are given appropriate assistance, along with arrangements for a follow-up visit. In addition, those who are identified as former smokers are given advice to prevent relapse, and persons who have never used tobacco are encouraged to remain tobacco free. The aim of these guidelines is to increase smoking cessation through improved understanding of the health consequences of smoking, better information about the availability and proper use of treatments, and the provision of encouragement and support.
Controlled studies have found that physician involvement, especially more extensive interventions, increases quit rates. This approach has also been found to be cost-effective since tobacco cessation interventions cost about $2500 per year of life saved, whereas mammography screening costs about $50,000 per year of life saved.
Based on a recent comprehensive review of the efficacy of different smoking cessation treatments, the PHS has recommended that all smokers receive counseling and support to quit preferably in combination with approved pharmacotherapy. Despite this treatment guideline, population-based surveys reveal that most tobacco users today are still not routinely receiving treatment assistance from their health care provider during visits. For example, a recent survey reported that tobacco counseling occurred in fewer than one-fourth of doctor visits by tobacco users, and cessation medications were prescribed on fewer than 3% of occasions. Studies have documented that utilization of evidence-based stop smoking treatments are lowest among those who are uninsured and have the greatest need for assistance in quitting tobacco (ie, those with mental health and other substance abuse problems). Encouraging smoking cessation is now recognized as an important part of medical care.
The guideline continues to emphasize use of the 5 A‘s in clinical settings: Ask about tobacco use, Advise to quit, Assess willingness to make a quit attempt, Assist in quit attempt, and Arrange for follow-up. The American Academy of Family Physicians has attempted to simplify this to 2 A‘s: Ask about tobacco use and Act to advise smoker to quit, assess interest in a quitting, assisting in organizing pharmacotherapy and arranging for follow-up. These systematic approaches to tobacco dependence require less than 3 minutes to deliver with the potential to result in behavior change. Other key points from the 2008 PHS clinical guideline include
The chronicity of tobacco dependence, requiring repeated assessment and multiple interventions to achievecessation.
The need for all health care delivery systems to systematically identify and document tobacco use status and to offer treatment to every tobacco user.
To provide both pharmacotherapy and counseling support to all patients making a quit attempt.
To offer every patient who uses tobacco at least a brief intervention.
Counseling support is effective in a variety of settings (eg, individual, group, or via telephone) and effectiveness increases with treatment intensity. Counseling should address both practical issues (problem solving/skills training) and social support.
The use of effective first-line medications (all forms of nicotine replacement therapy, bupropion, or varenicline) should be encouraged for all quit attempts and individualized as appropriate.
While counseling and pharmacotherapy are each effective when used by themselves, the combination is more effective than either alone for treating tobacco dependence.
Use of telephone quitlines should be promoted since counseling is effective with diverse populations and offers broad geographic reach.
Motivational messages can be delivered to tobacco users who are not currently interested in making a quit attempt.
Tobacco dependence treatments are efficacious and cost-effective; health plans and employers should ensure that all insurance plans include smoking cessation counseling and pharmacotherapy as covered benefits.
A standardized tobacco use assessment tool can help identify those individuals who are highly nicotine-dependent and/or lack the motivation and confidence to quit so that treatments options can be customized to each individual. Physician advice to stop smoking increases the likelihood that patients will try to quit and enhances the odds of those who do quit remaining off cigarettes. Long-term cessation rates approach 20% with counseling and increase to 30% when counseling is combined with pharmacotherapy.
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