Clinical Review

Smoking cessation: Tactics that make a difference

OBG Manag. 2008 March;20(3):35-44

Agnes O. Coffay, MD

Telephone “quitlines,” Web support, text messaging, and drugs all boost the quit rate—if you set the stage

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IN THIS ARTICLE

Web-based support helps smokers quit
Varenicline, nortriptyline, bupropion—strong allies in patients’ efforts to quit

References

1. Brown D. Nicotine up sharply in many cigarettes. Washington Post, August 31, 2006. Available at: www.washingtonpost.com/wp-dyn/content/article/2006/08/30/AR2006083001418.html. Accessed on September 4, 2007.

2. Agency for Healthcare Research and Quality. Clinical Practice Guideline. Treating Tobacco Use and Dependence. Rockville, Md: US Department of Health and Human Services Public Health Service; 2000. Available at: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2. chapter.7644. Accessed on September 4, 2007.

3. Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: A US Public Health Service report. JAMA. 2000;283:3244-3254.

4. Ask and Act: A Tobacco Cessation Program. Available at: www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html. Accessed on September 4, 2007.

5. Lancaster T, Stead LF. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2004;(4):CD000165.

6. Fiore MC, McCarthy DE, Jackson TC, et al. Integrating smoking cessation treatment into primary care: an effectiveness study. Prev Med. 2004;38:412-420.

7. Katz DA, Muehlenbruch DR, Brown RL. Effectiveness of implementing the Agency for Healthcare Research and Quality Smoking Cessation Clinical Practice Guidelines: a randomized, control trial. J Natl Cancer Inst. 2004;96:594-603.

8. Stead LF, Lancaster T, Perera R. Telephone counseling for smoking cessation. Cochrane Database Syst Rev. 2003;(1):CD002850.

9. Zhu SH, Anderson CM, Tedeschi GJ, et al. Evidence of real-world effectiveness of a telephone quitline for smokers. N Engl J Med. 2002;347:1087-1093.

10. An LC, Zhu SH, Nelson DB, et al. Benefits of telephone care over primary care for smoking cessation. Arch Intern Med. 2006;166:536-542.

11. Etter JF. Comparing the efficacy of two Internet-based, computer-tailored smoking cessation programs: a randomized trial. J Med Internet Res. 2005;7(1):e2.

12. Swartz LH, Noell JW, Schroeder SW, Ary DV. A randomised control study of a fully automated internet based smoking cessation programme. Tob Control. 2006;15:7-12.

13. Rodgers A, Corbett T, Bramley D, et al. Do u smoke after txt? Results of a randomised trial of smoking cessation using mobile phone text messaging. Tob Control. 2005;14:255-261.

14. Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2004;(4):CD000146.

15. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2004;(2):CD000031.

16. Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med. 1997;337:1195-1202.

17. Swan GE, McAfee T, Curry SJ, et al. Effectiveness of bupropion sustained release for smoking cessation in a health care setting. Arch Intern Med. 2003;163:2337-2344.

18. da Costa CL, Younes RN, Lourenco MT. A prospective, randomized, double-blind study comparing nortriptyline to placebo. Chest. 2002;122:403-408.

19. Hall SM, Reus VI, Munoz RF, et al. Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry. 1998;55:683-690.

20. Hall SM, Humfleet GL, Reus VI, et al. Psychological intervention and antidepressant treatment in smoking cessation. Arch Gen Psychiatry. 2002;59:930-936.

21. Prochazka AV, Weaver MJ, Keller RT, et al. A randomized trial of nortriptyline for smoking cessation. Arch Intern Med. 1998;158:2035-2039.

22. Gourlay SG, Stead LF, Benowitz NL. Clonidine for smoking cessation. Cochrane Database Syst Rev. 2004;(3):CD000058.

23. Hughes JR, Stead LF, Lancaster T. Anxiolytics for smoking cessation. Cochrane Database Syst Rev. 2000;(4):CD002849.

24. Jorenby DE, Hays JT, Rigotti NA. efficacy of varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation. JAMA. 2006;296:56-63.

25. Gonzales D, Rennard SI, Nides M. Varenicline, an α4β2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation. JAMA. 2006;296:47-55.

26. LeHouezec J. Why a nicotine vaccine? Clin Pharmacol Ther. 2005;78:453-455.

27. Tuller D. Scientists testing vaccines to help smokers quit. New York Times, July 4, 2006.

28. Fagerström K, Balfour DJ. Neuropharmacology and potential efficacy of new treatments for tobacco dependence. Expert Opin Investig Drugs. 2005;15:107-116.

Fast Track

Discuss your patient’s smoking at every opportunity—one study has shown that even brief advice can help

When a counselor telephoned smokers who were attempting to quit, the abstinence rate climbed from 4.1% to 7.5%

Toll-free quitlines provide patients with personal counseling—appealing to those uncomfortable discussing their smoking in a group

A Cochrane Review found that nicotine replacement nearly doubles a smoker’s chance of quitting

When compared with placebo, bupropion doubled a patient’s odds of quitting smoking

2 studies suggest that varenicline may be at least as good as—or better than—bupropion for long-term smoking cessation

Early studies suggest that nicotine vaccines may make abstinence from smoking easier to maintain

This research is supported by the Intramural Research Program of the NIH, National Institute on Drug Abuse. The author has no other financial relationships relevant to this article.

Practice recommendations

Recommend that your patients take advantage of telephone counseling—it improves both the quit rate and the long-term abstinence rate. Web-based cessation programs also support smokers in all stages of quitting.
Encourage patients to use both pharmacotherapy and counseling to improve abstinence. Several medications—including bupropion and varenicline—achieve comparable rates of quitting and long-term abstinence.
Train your office staff to help identify and counsel smokers.

CASE Smoker who uses OCs

Ann G. is a 34-year-old mother of two who has been coming to the office for her annual Pap smear for several years. Her medical history is significant only for her vaginal deliveries and mild gastroesophageal reflux. She takes oral contraceptives (OCs) and uses over-the-counter ranitidine hydrochloride (Zantac) as needed. On Ann’s most recent annual visit, the medical assistant, Tammy, takes her vital signs. The chart has a section about smoking status, and Tammy notes that Ann is a smoker.

During the office visit, the ObGyn explains to Ann that her smoking is a serious health risk and advises her to quit. She also informs Ann that she needs to find a new form of birth control next year, as smoking increases the risks of using OCs, especially after age 35. Ann nervously laughs off the warning.

When she returns the following year, Ann confesses to Tammy that she is still a smoker. When Tammy asks about quitting, Ann remains adamant: “No way—I can’t do it.” Nonetheless, during the office visit, the ObGyn raises the subject again, and Ann admits that she is afraid that quitting smoking will cause her to gain weight. The physician attempts to address Ann’s fears, talks about other birth control options, and gives her a 3-month prescription for OCs. Before ending the visit, the ObGyn tells Ann that they will discuss what to do about birth control when she returns in 3 months.

Ann faces an uphill battle. The amount of nicotine in cigarettes is increasing,¹ making it harder to quit. The good news is that the treatment of tobacco addiction is constantly improving, and the number of tools in our arsenal is growing. In fact, there are many resources that we can try before turning to the prescription pad. However, when needed, pharmacotherapy is an important adjunct in a patient’s struggle to achieve abstinence.

“5-A” strategy sets stage for success

Treating Tobacco Use and Dependence, a useful publication from the Agency for Healthcare Research and Quality (AHRQ), offers guidelines on many aspects of tobacco cessation, from counseling to pharmacotherapy to reimbursement.^2,3 The guidelines break the smoking cessation process into five A’s:

Ask each patient about her smoking status.
Advise each patient who smokes that she needs to stop smoking.
Assess your patient’s willingness to make a quit attempt in the next 30 days.
Assist your patient in making this quit attempt or encourage her to consider a quit attempt later.
Arrange close follow-up of any quit attempts to help prevent relapse.

The Ask and Act program from the American Academy of Family Physicians outlines a similar strategy.⁴ The program instructs physicians to Ask every patient about her tobacco use and to Act to help her quit, via on- or offsite counseling, telephone “quitlines,” patient education materials, self-help guides or Web sites, cessation classes, and pharmacotherapy.

Take advantage of every opportunity you have to discuss the issue with patients; short conversations can make a difference. A Cochrane review of 39 trials including 31,000 smokers revealed that even brief advice—simply encouraging patients to quit—was statistically significant in helping the smoker quit (odds ratio [OR]=1.74; 95% confidence interval [CI], 1.48–2.05).⁵ The pooled data generated a quit rate difference of 2.5%: for every 40 people who were told to quit, one more smoker would.

Empower the office staff