“The health care system has long been recognized as a logical and potentially productive means of reaching smokers with a cessation message and promoting their successful cessation.  Approximately 70 percent of smokers see a physician each year, creating the potential to reach large numbers of smokers with a cessation message.  The fraction of patients who report having been advised in the last year by their physician to quit smoking remains too low…” – National Cancer Institute’s monograph:  Population Based Smoking Cessation:  Proceedings of a Conference on What Works to Influence Cessation in the General Population

After reading this section, please consider reviewing the remainder of the website with respect to possible areas of concern with your patient population.  Are there frequent excuses your population use to not start a smoking cessation program?  Are there some statistics you feel might benefit your patients when you talk with them?  Please feel free to email any questions, concerns, comments or additions.  Our goal is to help people stop smoking.  Your help as a healthcare provider, this website, these methods, pharmacologic / nutritional assistance, and a good support system will increase your patients’ long-term smoking cessation success rate.

Why should we be concerned with having our patients stop smoking now?  The problem is only half of people with the most common lung disease of smokers, Chronic Obstructive Lung Disease (COPD), are clinically recognized.  It is estimated 10%-15% of people over the age of 55 have significant COPD.  Smoking is the major contributor to this.  As you know, COPD is irreversible.  Once you have it, it is progressive and cannot be cured.  There currently is no test available to tell which person will get COPD or, of the people who will eventually get it, how soon.  The reason COPD is underestimated is because it is not usually recognized and diagnosed until it is clinically apparent and moderately advanced.  Most start smoking as teenagers but are diagnosed and have come to clinical attention with COPD in their later stages of life after several decades of smoking.  This is because of our very large lung reserve.  As with any lung disease, it is not going to become clinically apparent until one has destroyed 50% or more of their underlying lung function.  This is why, for a chronic disease such as COPD, it doesn’t become manifest until a very late stage. 

Two major areas of concern focused upon in this section:

1) Should we, as healthcare providers, even be concerned with assisting in the smoking cessation process?  Will the adolescents and young adults listen to their healthcare provider?  If a person is a middle-aged smoker (aged forty, fifty, or sixty), is an intervention worth while?  Is it too late?  Much of the total risk of lung cancer is avoidable by quitting at age 50.  This is also true of COPD.  The heart disease benefit is applicable to all ages.

2) What can we, as healthcare providers, do to help assist people in their smoking cessation plans?  Unfortunately healthcare providers are not an overwhelming influence for people to decide to stop smoking—increased difficulty in access to smoking areas and increased cost of cigarettes (usually in the form of increased taxes) are.  However, you can just about double the rate of a cessation attempt in a population of individuals coming through your office by giving them a healthcare provider recommendation to quit.  Our job as healthcare professionals is to provide access to information, cessation assistance, and medications.

“Healthcare providers have an important role in evaluating, advising patients, and managing their practices in a way that facilitate and encourage patients to maintain a smoking free life.”

A healthcare provider’s goals should be:

1) To get patients not thinking about smoking cessation to think about it.

2) To help patients thinking about it to quit.

Healthcare providers can be a valuable asset to a smoker once they decide to quit.  We can also be a “united front” in the effort to discourage smoking.  We should not, with a single intervention, guarantee success. 

Who should you treat?  First and foremost, you need to identify all smokers in your practice.  Ask everyone.  One of the easiest ways to do this is to have a notation by the person who does the initial interview or vital signs.  “Do you Smoke?”  Yes or no.  Nothing in between.  No other response is necessary.  Do not allow your patients to minimize their smoking habit.  “Yes, but only on the weekends.”  “Yes, but I only smoke a cigarette or two a day.”  Not acceptable answers.  This question has to be a part of your system of providing healthcare.   It is a vital sign.  Right there with temperature, heart rate, and blood pressure.  It is presented to you on the chart as such.  It is reviewed by you as such.  You have a prompt with each patient you see regarding the need for a smoking cessation intervention. 

VITAL SIGNS

Blood Pressure:______________________________

Pulse: _____________ Weight: _______________

Respiratory Rate: ___________________________

Tobacco Use (circle one):   Current   Former   Never

Do not rely on your memory to Ask.  If you do, when you forget to Ask the right person, you are reinforcing in their mind your commitment to help them is weak or gone.  They are never too old, they’re never too young, they’re never too sick and they’re never too healthy, to be Asked.  Quantifying the smoking to pack-years can be helpful if you are considering diagnosis and treatment of a suspected smoking-related health concern or illness.  Using the Fagerstrom Test for Nicotine Dependence is a wonderful tool to help people gain interest in smoking cessation.  But first, identify your smokers.

Please remember:  (as mentioned again below) “Among those who smoked everyday, 41.2% reported that they stopped smoking for greater than or equal to one day in the preceding twelve months in an attempt to quit.”  (Centers for Disease Control and Prevention.  Cigarette smoking among adults—United States, 2002.  MMWR.  2004;53(20):427-431) 

Your patients want to quit.  They are in a continual cycle of:  1) thinking about quitting or 2) interested in quitting.

But for the purposes of smoking cessation, if they smoke, a simple “Are you ready to quit?” should be asked in a nonjudgmental/factual manner.  The same way you would ask a person how a new diet is going or if there are any side effects to a new anti-hypertensive medication.

The answer allows you to Assess their level of dependence and their readiness to quit.  If the response is a definitive NO, you need to Advise them in a clear, strong, personalized, quick, again nonjudgmental manner: “I, as your healthcare provider, am telling you that this is the most important thing you can do for your health and I will help you” and move on.  Five second intervention.  If the NO seems questionable, refer them to one or more of the quizzes on our website.  It is difficult, if not impossible; to convince a smoker to quit and it is not your job.  Don’t fight with your patients.  Limit the “non-yes” patients to a maximum of 45-90 seconds.  Any longer than this is unsustainable in a daily practice.  Smoking cessation is a long-term, not a short-term, goal.  Smokers know it is bad for them.  This is not a failure on your part; it is one step toward success.  You have planted a seed.  You have allowed your patient, for however brief or extensive, to think about it.  Studies show “Among those who smoked everyday, 41.2% reported that they stopped smoking for greater than or equal to one day in the preceding twelve months in an attempt to quit.”.  This is an incredibly important statistic.  This should be your constant motivator to continue to pursue smoking cessation with your patients.  Ask them again at their next visit.  Their “no” today might turn into a “maybe” or “yes” tomorrow.  My thought process:  there is a 41.2% chance that I will catch a patient in the “yes” mode to quitting at least sometime within the framework of an office visit or interaction.   In my personal life I am constantly looking for new and innovative ways to help people stop smoking.  What are the cues people might be willing to stop smoking?  How can I approach the subject without automatically getting a barrier thrown up?  Should I just walk up to a group of smokers and start ranting and raving?  A healthcare provider has the advantage in their place of intervention.  You have the patient, usually one-on-one, away from their smoking buddies.  Hopefully you have built a rapport with them.  They trust you.  It really is your obligation to at least attempt to have them consider smoking cessation.  It doesn’t matter what specialty you practice because smoking cessation has advantages in every setting.  Whether you are a primary care provider, a surgical specialist, or a non-patient-care specialist, smoking has an impact on your practice.  If you know a person has high blood pressure, a tumor, a bleeding disorder, or whatever, would you not treat them or ask them about a treatment plan?  Of course you would. 

Your patients need a consistently delivered and effective message to stop smoking.  The goal is to hit the person at the right time, when they are ready.  This may be with your first visit; it may be after ten years of working with this patient.  Do not give up.  Do not allow your patient the benefit of seeing you may have lost faith in them.  Patients have a way of testing healthcare providers without us even knowing it.  Be gentle but firm.  Ask about their smoking with each visit.  This was NOT the approach I used with my father.  I basically pestered him unrelentingly.  It was to the point my father would either threaten to walk away or hang up the phone if I persisted.  Hind sight being 20/20 I may have been building a wall between my father and myself.  Perhaps if I continued to casually mention the health hazards and how smoking was affecting his life, he might have quit on his own.  If I had allowed him to come to the realization himself, he might be alive today.  Thankfully my mother has stopped smoking.  I’m not sure if I had an impact, but I certainly did not persist in as harsh a manner as I did my father.  My sister still smokes…

Of the people who respond YES, they are ready to quit, you now have the smoking cessation cycle.  You are ready to Assist them.  Unfortunately nothing works for everyone and no one responds to everything.  A person’s interest may be great one day, and low the next.  The key to smoking cessation is persistence and intensity.  The more intense, the more success.  The more willingness to persist, even after a relapse, stressful situation or overwhelming urge, the better. 

At this point is it best to remind your patient the risks of continuing to smoking (reinforcing the need to quit), the benefits to smoking cessation, the roadblocks they are likely to encounter, withdrawal symptoms, and cravings in the future.  All of these can be found in our website.  Even with the best plan, some people will relapse into smoking again.  Many will be successful, long-term quitters.  The key is to continue to encourage both the former smokers and those wanting to go through the smoking cessation process.  Constant reinforcement is necessary for both sets of patients.  This is where, regardless of which type of pharmacologic approach is used, the Personal Planner for Success becomes such an important factor.  When used properly, it helps promote positive reinforcement in their smoking cessation efforts.  It is a “friend” when no one else is around.  It is a coping mechanism when urges hit.  It helps prevent relapse by identifying possible factors which might cause relapse.  It should most definitely include annotation of all past attempts and why they failed.  Or did they?  Were they successful for a time but a certain situation at a certain time and place cause a breakdown?  Very important for people to identify themselves.  This is also a process which does not happen overnight.  They have to change their entire mindset about smoking.  Gradually, with time, support, reflection of ones self, and positive encouragement, long-term smoking cessation is achieved. 

Have options available to your patients.  Nothing works for everyone, and no one responds to everything.  But everyone will respond to something and everything works for someone.  Takes a little time to digest those statements, but it is true. 

Most commonly used smoking cessation treatments available:

• Gold Standard => 6-8 week intervention program with medication (only 2%-3% utilize this method).
• Telephone counseling.  Many organizations and state-funded programs offer toll-free support plus scheduled call-back.  A few are mentioned in our website.
• Self-help materials.  Minimal effect on their own.  Usually used as a bridge to more in-depth options.  The information can be digested during their free time in a less pressured environment.  Better used as coping mechanisms or thought-redirecting options.
• “Cold Turkey” – Abrupt cessation of smoking.  Advantage is no side effects assuming the patient can tolerate the cravings and withdrawal.  Disadvantage is, when used alone, only 5%-7% of smokers will remain abstinent long-term.
• Nicotine replacement and antidepressants – Both work.  Both double the long term success rate.  Disadvantage is the possibility for a person to become dependent on a nicotine replacement product.  It is not recommended to continue to smoke while you are using nicotine replacement therapy.  There is a possibility of overdose on nicotine.  This can cause headaches, nausea, confusion, and vomiting.   However long-term use has not been found to be harmful. 
  • Nicotine gum, lozenges – Advantage is the immediate nicotine burst.
  • Nicotine patch – Easier to use and probably more effective than the gum or lozenges.  The nicotine patch is a taper-down method.  Start at the appropriate amount for a specified time and taper down to the next lower level for a specified time.  Abrupt withdrawal of the nicotine patch without tapering can cause withdrawal symptoms.
  • Many feel both used together, nicotine patch (to provide background level of nicotine) with gum/lozenges (for cravings) is an effective approach.
    • Disadvantage of patch, gum, and lozenge:  The time in minutes to plasma nicotine level.  The patches and gum are designed to have a slow rise time.  Cigarettes have a huge burst particularly from the pulmonary venous absorption of the drug.  This causes a tremendous level of nicotine to the brain very quickly.  That is what the smoker is looking for.
  • Nicotine nasal spray – Offers very rapid onset.  Disadvantage is it can be irritating to the nasal passages.
  • Nicotine oral inhaler – Very rapid rise time of nicotine.  Disadvantage is the nicotine can be irritating to the back of the throat.  Ironically there are people who cannot tolerate the cough sometimes associated with the oral inhaler.
  • Nicotine lozenge – Useful for people with difficultly chewing gum.  More than expected is needed when used as the sole smoking cessation aid, need to use nine to fifteen lozenges per day for six weeks.  Most people are not aware of this and only use them when they have cravings.  Lozenges do not work well when used only for cravings.
  • Bupropion (Zyban®, Wellbutrin®) is the antidepressant most often used.  There is an incidence of depression which is associated with, if not caused by, cigarette smoking.  Needs to be started 7-10 days prior to the Quit Date.  This is difficult for most people to do.  They are not prepared to wait a week or two before trying to quit.  If you make them wait to quit, then they tend not to quit.  It has shown to be effective.  It also increases overall smoking cessation when used in combination of other modalities.  Bupropion is an antidepressant.  There is nothing about using it as a treatment for smoking cessation which makes it any safer than its use to treat depression.  Need to be aware of the side effects and contraindications.

o        Chantix® (vareniciline)-- Approved by the FDA in May 2006 as a smoking cessation drug.  Chantix® acts at sites in the brain affected by nicotine and may help those who wish to stop smoking by providing some nicotine effects to ease the withdrawal symptoms and by blocking the effects of nicotine from cigarettes if users resume smoking.  On Nov. 20, 2007, the FDA issued an Early Communication to the public and health care providers that the agency was evaluating postmarketing adverse event reports on Chantix® related to changes in behavior, agitation, depressed mood, suicidal ideation, and actual suicidal behavior. }

• A+ Smoker’s Control™ - Designed to be a nicotine-free nutritional support aid.  One of the main ingredients has been used in third world countries to help heroin addiction.  Other ingredients have a calming effect; serve as antioxidants; and support the respiratory, immune, digestion, circulatory systems.
• Alternative modalities:  anticholinergic injections, laser, acupuncture, and hypnosis.  All of which have worked, in varying degrees, for many people.

Of course we favor A+ Smoker’s Control™, but we recognize the need to provide information on the other methods mentioned above.  Whichever method is selected, it is important to encourage, don’t discourage.  The biggest impact you have is getting your patients to make a cessation attempt.  Consider combinations of methods as necessary.  A+ Smoker’s Control™ works well with all non-nicotine replacement therapies:  antidepressants, laser, injections, acupuncture, and hypnosis.  You need to be prepared to have something available your patient hasn’t tried before.  Make no mistake, these modalities are effective, they do make a difference, and they do increase success rates.   Combinations increase success rates even more and also give the problematic quitter more alternatives.  “You used the patch last time which was effective for a while, why not try the patch and gum?  The patch and lozenges?  The patch and an antidepressant.  Try something new and different.  Try A+ Smoker’s Control™.  Try A+ Smoker’s Control™ with an antidepressant.  A+ Smoker’s Control™ and anticholinergic injections.”  When unsuccessful with one modality, keep your patients motivated and give them alternatives.  With the group of A+ Smoker’s Control, antidepressants, laser, injections, acupuncture, and hypnosis, you have 720 possible combinations (remember 6! from your statistics course?)  Realistically if you only wanted to use any two of the above you would have 30 possible combinations.  Any three of the above you would have 120 possible combinations.  With the nicotine replacement group plus antidepressants, laser, injections, acupuncture, and hypnosis, you have 3,628,800 different combinations!  Any two of this group gives 90 and any three of this group gives 720 possible combinations.  As you can see, you will always have a new method to give your patients!

You need to address both the addiction and the behavior.  The pharmacologic addiction and its neurologic manifestations (withdrawal symptoms) last seven to 30 days.  Cravings, however, persist forever.  People can be former smokers for years and a trigger cause a relapse or severe craving.  It could be a place such as a restaurant, diner or bar; it could be a life event, a death, hospitalization of a loved one, divorce, or change in job.  The more you can identify and disrupt those triggers; the more a person will continue to be successful in their ex-smoker status.  This is where the Personal Planner for Success has one of its major roles in smoking cessation.  One of the many sections is to identify a person’s triggers in-depth.  Many examples of triggers are given and it is emphasized to continue to update their Personal Planner for Success whenever possible.  People are encouraged to formulate their own plan to combat those triggers and possible relapse situations.  The motto of the Personal Planner for Success is RIPI:  R-Reflect, I-Identify, P-Plan, I-Initiate.

The more intense a program, the greater the success.  More is better.  If a person goes to an in-house 6-8 week program, the more sessions, the better.  Unfortunately it is a minority of person who are willing to take advantage of these types of programs.  Intensity is also true of other treatment modalities:  combinations of medications, reading, support systems, listening to tapes or CDs – more is better.  Persistence is even more important than intensity.  It is important for you as a healthcare provider to be persistent in your commitment to help people stop smoking.  It is also important for you as a healthcare provider to help your patient persist.  The first try might not be successful.  The second try might not be successful.  The third through fifth times might not be successful.  You need to help the patient update their treatment modality and thought process – RIPI – Reflect, Identify, Plan, Initiate.  Relapse possibilities exist – RIPI.  Patients need to be reminded a relapse is not failure; it’s another chance for success.  It’s one more entry in their Personal Planner for Success.  The average smoker quits three to fourteen times before being successful.  I don’t normally remind people of this but it is true.  Both you and your patient need to be prepared for this.

Arrange follow up.  Another appointment at your office is preferred, however time, monetary, and insurance constraints often prevent this.  An alternative would be a letter, on or before their Quit Date, with your signature and letterhead, as a reminder and reinforce your commitment to help.  An email or telephone call by your support staff is another alternative.  Your patients need to know they are not alone and have your support.  An unexpected communication by you will mean the world to your patient.  You are committed to helping them.  At the very least, at their next scheduled appoint, you need to ask them how it went.  The last thing you want is for your patient to feel you didn’t really care about their smoking cessation attempt, that is wasn’t really important.  The follow up visit, whether specifically for their quit attempt or for another scheduled appointment, is a golden opportunity to review with them possible relapse triggers/identifiers, prevention, and management.  Again, their Personal Planner for Success is vital.  They should be able to tell you about relapse and how they are preparing against it!

General to all smoking cessation attempts:

• Set a Quit Date. 
• Have them tell everyone around them they are going to stop smoking (Mobilize social support). 
• Anticipate challenges (Use of the Personal Planner for Success).
• Offer counseling.  The gold standard is a six to eight week intervention program with medications, but only 2%-3% of patients are willing to go this route.  Today, however, there are telephone, web-based, email, chat room / forum, and in-person support systems (many are listed in our website).  Support books, audio tapes/CDs are available.  These can even be borrowed from your local library.
• Offer smoking cessation aids or tools.  Medication is the principle form of assistance most people are currently using.  Please consider A+ Smoker’s Control™ in your medication algorithm.  Be open to other forms of assistance:  anticholingeric injections, laser, acupuncture and hypnosis.
• QUIT on their Quit Date.
• Follow up with your patient.  Preferred would be a face-to-face appointment.  At a minimum a letter, email or telephone call.

To recap:  the goal of this section is to provide a method healthcare providers can effectively address the issue of smoking cessation.  Critical to this is:

1. Follow the 5 As mentioned in this section.
2. Document whether each of your patients smoke.
3. For your smokers, ask if they are ready to quit.  If they are unsure or it seems questionable, have them utilize the quizzes on this website.  Have material ready for them if requested but do not overwhelm them.
4. If they say they are not ready to quit, reinforce it is the best thing they can do for their health and move on.  Limit your intervention to 45-90 seconds (or less).
5. Be as available as possible to answer questions.  Reference this website if time is of the essence and you need to move on.  Point out specific features which might be of benefit to them such as our quizzes, statistics, benefits, search feature, guidelines, Personal Planner for Success, Support section, etc.
6. If your patient is ready to quit, have multiple avenues of approach to assist in smoking cessation.  Of course we are a little biased to use A+ Smoker’s Control™, but have available your particular methods whether with nicotine replacement therapy, antidepressants, gums, lozenges, patches, nasal and oral inhalers, pills, laser, injections, etc.  Explore different combinations so you don’t get caught off guard when your patient says “I’ve tried that and it didn’t work.”  Nothing works for everyone, and no one responds to everything.
7. Continue to ask each patient if they smoke and, if they quit, whether they have continued to be successful.  Have some contact with your recent “former smokers” to instill your concern and support.  Part of your plan for them prior to their smoking cessation attempt should include relapse prevention.  A very effective method for this is the Personal Planner for Success and having a supply of A+ Smoker’s Control Nutritional Support Maintenance available during weak points in their success.

ADDENDUM:

BRIEF STRATEGIES TO HELP THE PATIENT WHO IS WILLING TO QUIT – This is the underlying theme to this section of our website.  The famed “5 As”

1. ASK: Systematically identify all tobacco users at every visit.  Implement an office wide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco use status is queried and documented.  What you are doing here is identifying patients at risk. 

2. ADVISE: Strongly urge all tobacco users to quit.  In a clear, strong, and personalized manner, urge every tobacco user to quit.  You need to make sure your patient understands your willingness to provide a strong statement about the need to stop smoking. 

3. ASSESS: Determine willingness to make a quit attempt.  Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days).What behavioral stage of willingness is your patient?  This is one of the reasons healthcare providers do not feel they are good smoking cessation counselors is because most patients don’t quit smoking.  But some do.  And if you continue to give a supportive message you help patients move along the behavioral circle that allow them to achieve long term success.

4. ASSIST: Aid the patient in quitting.  Help the patient with a quit plan; provide practical counseling; provide intratreatment social support; help the patient obtain extra treatment social support; recommend use of approved pharmacotherapy (except if contraindicated); provide supplementary materials.  Once identification of a smoker is made, a determination of willingness to quit established, there is now the need to assist your patient to stop smoking.  Keeping in mind the need for follow up during your assistance as well as after the plan is complete. 

5. ARRANGE: Schedule follow-up contact.  Schedule follow-up contact, either in person or via telephone.  Your practice should include follow up with patients at each visit.  Continue to monitor this as a vital sign.  Remember, these are lifetime behaviors that tend to relapse.  Just as it is recommended to attempt to identify all smokers, it is just as important to identify those who have quit are continuing to quit.  With each clinic visit.  It is a poor message to be a strong supporter of smoking cessation then not be concerned the person has remained smoke free.  Just as each beginning has an ending, each ending has a new beginning.  Your patient needs to be aware you will be there if they relapse.  One of the few ways they will know this is if you ask of their continued success before they relapse.