RESEARCH to PRACTICE

Promoting Cessation of Tobacco Use

Glen D. Morgan, PhD; Brion J. Fox, JD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 12 - DECEMBER 2000

Tobacco exacts an exorbitant toll on the nation's health, causing more than 450,000 deaths yearly. Although rates of smoking (the most common form of tobacco use) among adults have decreased in the past two decades, the decline has recently leveled off. Of additional concern is that youth tobacco use is increasing (1). A combination of recent scientific advances and social, legal, and public policy developments provides an unprecedented opportunity to reduce the burden of death and disease caused by tobacco use (2). Reducing tobacco use among adults and adolescents is an important public health goal.

Guideline for Cessation

Physicians and healthcare systems will play a key role in achieving this objective. This effort will undoubtedly be facilitated by the recently released Public Health Service Clinical Practice Guideline, "Treating Tobacco Use and Dependence" (3,4). The guideline was developed by a consortium of seven government and nonprofit organizations that reviewed more than 6,000 articles to identify empirically based and validated assessments and treatments for tobacco dependence.

The report contains evidence-based information about behavioral counseling, first-line pharmacologic therapies (sustained release bupropion hydrochloride and nicotine-delivery agents such as gum, patches, inhalers, and nasal sprays) and second-line pharmacologic therapies (clonidine hydrochloride and nortriptyline hydrochloride) that are effective in helping patients to stop using tobacco. An overarching conclusion of the panel was that tobacco cessation treatments are effective and extremely cost-effective compared with other routine medical and disease-prevention interventions (3,4).

Healthcare Providers as Facilitators

Since most tobacco users see healthcare practitioners yearly, systematic institutional identification and tracking of these patients is a critical first step to effective care. The guideline concludes that tobacco dependence should be viewed as a chronic disease, not unlike diabetes or hypertension. Effective treatments, however, are available, and clinicians should be ready to treat their patients through periods of relapse and remission. As such, every patient who uses tobacco should be offered a treatment shown to be effective. Even a brief consultation (3 minutes or less) at each clinic visit will significantly improve abstinence rates.

Steps to Cessation: The Five A's

The guideline provides different brief interventions for treating patients based on their smoking status (4). Physicians should:

• Ask patients if they use tobacco, and include tobacco-use status as a vital sign. An officewide system can be implemented to ensure that all patients are queried regarding their tobacco use.
• Advise patients to quit—advice should be clear, strong, and personalized.
• Assess willingness to make a quit attempt in the next 30 days. Provide a motivational intervention for those unwilling to quit at this time.
• Assist patients in their efforts to quit: (1) Patients should set a quit date and remove tobacco products from their environment. (2) Provide practical counseling. Total abstinence is the key objective. Patients should limit alcohol use and anticipate and plan for challenges and triggers. (3) Offer support and suggest that patients seek support from their friends and family. (4) Recommend appropriate first- or second-line pharmacotherapies.
• Arrange follow-up within the first week after the quit date to prevent relapse.

Motivating Patients: The Five R's

Physicians who wish to motivate patients to quit using tobacco should explain "the 5 R's":

• Relevance: Have patients indicate why quitting is personally relevant.
• Risks: Discuss potential negative consequences of tobacco use, including acute and long-term health effects and environmental risks.
• Rewards: Review potential benefits to stopping tobacco use, such as improved health and cost savings.
• Roadblocks: Have the patient identify barriers or impediments—such as withdrawal symptoms, weight gain, and depression—and discuss approaches to address these barriers.
• Repetition: Repeat the motivational intervention at every visit of the reluctant patient.

Relapse Prevention and Counseling

Patients will relapse, and the following steps should help patients who are making an attempt to quit:

• Congratulate success, renew commitment, and remind patients that a lapse can be used as a learning experience.
• Encourage patient problem solving.
• Have patients identify specific problems that threaten abstinence and assist them in responding to these problems.

Tools to Help Patients

Physicians will need to play an active role in helping their tobacco-using patients to quit. With the publication of the evidence-based PHS guideline (3,4), physicians now have additional tools they need to fulfill this role.

References

1. National Cancer Institute: The nation's investment in cancer research: a budget proposal for fiscal year 2001, NIH Publication no. 99-4373, 1999
2. National Cancer Institute: Tobacco research implementation plan: priorities for tobacco research: beyond the year 2000, November, 1998
3. Fiore MC, Bailey WC, Cohen SJ, et al: Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD, US Department of Health and Human Services, 2000 (www.surgeongeneral.gov/tobacco/default.htm)
4. Fiore MC, Bailey WC, Cohen SJ, et al: A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. JAMA 2000;283(24):3244-3254

Dr Morgan is a program director in the Division of Cancer Control and Population Sciences at the National Cancer Institute in Rockville, Maryland. Mr Fox is a research fellow in the Center for Tobacco Research and Intervention at the University of Wisconsin Medical School in Madison. Address correspondence to Glen D. Morgan, PhD, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, Rm 4034 MSC 7337, Rockville, MD; e-mail to gmorgan@nih.gov.