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Use your power to help patients quit smoking: the more the message is repeated, the more likely it is to be heeded. 'It's a dose-response relationship.'.

NEW ORLEANS -- Yes, you can get your patients to quit smoking.

Physicians "really do have the tools to get people to quit smoking. We need to give patients a clear and unambiguous message," Dr. William C. Bailey said at the annual meeting of the American College of Physicians.

The more the message is repeated, the more likely patients are to heed it. "It's a dose-response relationship," noted Dr. Bailey, professor of medicine and Eminent Scholar Chair in Pulmonary Diseases at the University of Alabama, Birmingham.

Smoking cessation is a key preventive health measure, yet many physicians give it only perfunctory mention during routine office visits or skip over it entirely. In one survey of 2,963 office encounters in 38 primary care practices, tobacco use was discussed in just 21% of the visits, and even less often for repeat patients than during new patient visits (J. Fam. Pract. 50[8]:688-93, 2001).

Barriers perceived by physicians include lack of time, the belief that patients don't want to hear about it, or that they can't help patients quit. Yet data suggest that about 5% of patients will quit smoking after just one 3-minute, clear, unambiguous message from a physician. "If every physician did this, it would have a huge impact," said Dr. Bailey, who also is director of the University of Alabama's lung center.

Studies have shown that about 70% of smokers actually want to quit and therefore will be receptive to the message. In an HMO survey of 3,703 current smokers, the 1,898 who reported having been asked about tobacco use or advised to quit during the latest visit had satisfaction levels that were 10 percentage points higher than did those who did not report such discussions (Mayo Clin. Proc. 76[2]:138-43, 2001).

And as for having the tools to help your patients quit, the Department of Health and Human Services has devised a systematic approach based on "5 A's." It is part of a clinical practice guideline titled, "Treating Tobacco Use and Dependence," available online at These are the 5 A's:

1. Ask. Always ask every patient about smoking at every visit. Smoking status should be viewed as a vital sign, just like pulse and blood pressure. Most smokers start during adolescence, but some do begin later. And there are also patients who won't admit it the first time but might later on.

2. Advise. Once you identify a smoker, give a clear, strong message, such as: "As your health care provider, I must tell you that the most important thing you can do to improve your health is to stop smoking." Try to personalize the message by telling the patient about the impact of smoking on his or her own health condition, such as heart disease.

If the patient has young children, tell him or her that secondhand smoke has been shown to harm children's lungs as well, Dr. Bailey advised.

3. Assess. After providing the antismoking message, ask whether the patient is willing to quit at this time. If the answer is no, simply give a brief summary of the risks of smoking and the benefits of quitting, then stop. "Just try to motivate them, but don't nag," he advised.

4. Assist. For patients who express a desire to quit, help them come up with a plan. Provide them with handouts (available from groups such as the American Lung Association and the American Cancer Society) and refer them to hospital- or community-based support groups, he said.

Pharmacotherapy should be recommended and prescribed for most patients. (See box.) Bupropion SR and the various forms of nicotine replacement (including gum, inhaler, nasal spray, patch, and lozenge) are all first-line therapies. Different patients do better with different therapies, so the choice must be individualized. "All are trial and error," he noted.

Help the patient set a quit date, ideally in about 2 weeks. During that time, the patient should think about which cigarettes are the most difficult to resist and make plans to cope. The patient may need to avoid certain situations--such as the local bar or the weekly poker game--until the cravings have subsided.

5. Arrange. Schedule a follow-up visit within 1 week of the quit date. In the meantime, have a nurse or assistant call the patient during the week. Most relapses occur within the first 2 weeks, so "don't let them go long without checking on them," Dr. Bailey advised.

At the follow-up visit, congratulate successes and encourage continued abstinence. Ask patients how quitting has helped them.

If they've used tobacco during the week, remind them that it's a learning experience, and that relapse is consistent with the chronic nature of tobacco dependence. "You don't want them to think of it as a failure. They need to get right back up and try again." Dr. Bailey said.

The average successful quitter has failed an average of six previous quitting attempts. "Almost anybody can quit smoking no matter how addicted they are. You just have to hang in there with them," Dr. Bailey said.

But there is no question it's worth the effort. "Getting someone to quit smoking is more cost effective from a prevention perspective than treating hypertension or just about anything else we do and spend money on ... it's a worthwhile endeavor," Dr. Bailey said.

RELATED ARTICLE: Rx Therapies for Smoking Cessation

Bupropion SR and nicotine replacement are the recommended pharmacotherapies for smoking cessation, Dr. Bailey said.

Pharmacotherapy is advised for most patients who want to quit smoking. The following agents all work for a proportion of patients, so the choice must be individualized.

Bupropion SR

The only nonnicotine medication approved by the FDA for smoking cessation, bupropion is presumed to reduce cravings by blocking neural reuptake of dopamine and/or norepinephrine.

Available by prescription only, it is contraindicated in people prone to seizures, those on an MAO inhibitor in the previous 2 weeks, those with a history of anorexia or bulimia, and current users of Wellbutrin. Side effects include insomnia and dry mouth.

Dosing, which should begin 1-2 weeks prior to the predetermined quit date, is 150 mg orally once daily for 3 days, then 150 mg twice daily for the next 7-12 weeks. The drug can be used for maintenance up to 6 months. No taper is necessary at the end of treatment.

Some patients do well using both bupropion SR and a nicotine product, although such combination use is not FDA approved, he noted.

Nicotine Replacement Therapies

These should be started after the patient has stopped smoking. They are supplied as a steady dose in patch form, or self-administered as gum, lozenge, inhaler, and nasal spray. The self-administered products should be used on a scheduled basis initially before being tapered to ad lib use and eventual discontinuation.

Most patients should not continue taking nicotine products for more than 6 months, although about 9% will actually become addicted to them. "We don't recommend it, but it's safer than actual cigarettes," Dr. Bailey said.

Although nicotine replacement products can all cause vasospasm, there is no evidence that they increase cardiovascular risk. Still, they are contraindicated in patients who have had a myocardial infarction within the past 2 weeks, those with serious arrhythmia, serious or worsening angina pectoris, or accelerated hypertension.

Nicotine gums and lozenges should be "parked" in the mouth and allowed to absorb. A common mistake is to keep chewing the gum--this will result in stomach upset. Be sure the patient is using a high enough dose. Those smoking two or more packs per day should start with the 4 mg/day dosage, he advised.

Nicotine patches, available both by prescription and over the counter, come in different strengths. A new patch is applied each morning; having the patient rotate the sites can reduce irritation.

The nicotine inhaler, available by prescription only, requires frequent puffing. Eating or drinking during administration should be avoided.

Nicotine nasal spray, also available by prescription only, should not be sniffed, swallowed, or inhaled. Initial dosing is 1-2 doses/hour, increasing as needed but not to exceed 40 doses/day.

Combined use of two nicotine replacement products is not FDA approved but has been shown to be more effective than using just one product. Some patients respond to the use of a steady-state product such as a patch, gum, or lozenge along with "hits" of nasal spray, but patients must be cautioned to avoid overdosing, Dr. Bailey said.


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Title Annotation:Clinical Rounds
Author:Tucker, Miriam E.
Publication:OB GYN News
Date:Oct 1, 2004
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