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Clinical Reviews

Smoking cessation: Tactics that make a difference

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

March 2008 · Vol. 20, No. 03


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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:

  1. Ask each patient about her smoking status.
  2. Advise each patient who smokes that she needs to stop smoking.
  3. Assess your patient’s willingness to make a quit attempt in the next 30 days.
  4. Assist your patient in making this quit attempt or encourage her to consider a quit attempt later.
  5. 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

Enlisting the help of the office staff can have a significant impact on the health of patients. Fiore and colleagues evaluated a proactive approach in which medical assistants, while assessing smoking status, invited all smokers to participate in a cessation study.6 (The assistants received periodic thank-you gifts for their efforts.)

Participants were randomized to self-selected treatment or nicotine replacement therapy (NRT) patches, with or without a support program. Some who received the patches and support program also received individual counseling. The result: Most smokers were open to encouragement to quit smoking. The 13% point-prevalence abstinence rate 1 year out was comparable to the rate observed (14%) in smokers volunteering for NRT studies in the Cochrane review of 39 trials noted earlier.5

Likewise, in a randomized controlled trial (RCT) involving community-based primary care clinics, Katz and associates demonstrated that intake clinicians can also play an important role in smoking cessation.7 In the study, researchers trained intake clinicians (including registered nurses, licensed practical nurses, and medical assistants) to identify smokers, provide brief counseling, and assist in their preparation to quit. Patients were offered vouchers for patches and a counselor’s business card. Intake clinicians received periodic feedback on their performance based on exit interviews of the patients. These interventions had a statistically significant effect in moderate-to-heavy smokers in quit attempts, quit rates, and continuous abstinence.

CASE…continued A change of heart

At the 3-month follow-up, Tammy learns that Ann is still smoking—but she now wants to quit. Ann says that she found a pack of cigarettes in her 14-year-old daughter’s backpack, and feels that the only way to prevent her from getting hooked is to set a good example.

Tammy gives her the state’s quitline number, suggests some online quitting programs, and works with Ann to choose her target quit date and to pick the Web-based program she is going to use. Ann likes the fact that she can go online whenever she needs support. She also likes being able to put her quit date into the system so that the program will give her timely reminders of all her reasons to quit when she logs on.

The ObGyn writes prescriptions for varenicline (Chantix) and OCs and tells Ann to come back in 4 weeks. For her part, Tammy adds Ann to the list of patients she calls and will get in touch the day after Ann’s quit date. Tammy makes this her practice with patients because she knows that one well-timed phone call can be the key to a successful quit attempt.

Outside support improves abstinence rates

Improving your patients’ chances of long-term abstinence hinges, in part, on making the most of outside support. In many cases, your patients can take advantage of it without leaving their homes.

Quitlines increase quit rates, reduce relapse

Telephone counseling is an effective support system.8 Smokers who call to a single number (800-QUITNOW)—a service provided by the National Cancer Institute (NCI)—are directed to the quitline for their state. Smokers can also call the NCI directly at its quitline (877-44U-QUIT). Calling a quitline provides smokers with real-time counseling and information about how to quit smoking. Quitlines can be appealing to patients who are uncomfortable discussing their smoking in a group—and they are free to the patient.

Evidence supports the use of such help lines. In their study of the California Smokers’ Helpline, Zhu and colleagues tested a proactive protocol where smokers were funneled into a research trial when the help line was overwhelmed.9

The smokers in the treatment arm of this RCT were assigned a counselor who called the smokers as many as six times, following a relapse-sensitive schedule. The 12-month abstinence rate increased from 4.1% to 7.5% (P<.001) in the group that had close telephone contact. This improved quit rate reflects both an increase in the percentage of smokers who quit and, more importantly, a decrease in quitters who relapsed.

Another prospective RCT enrolled patients from Veterans Affairs (VA) medical centers and involved the same proactive telephone protocol that Zhu and associates used.10 The treatment group was offered telephone counseling as well as pharmacotherapy; the control group had access to the regular smoking-cessation program of the VA system. Quit rates were similar in both groups if the participant utilized both counseling and pharmacotherapy: 12.7% in the control group and 11.9% in the treatment group. However, only 18% of patients in the control group used both services. Among patients in the treatment group, 88% utilized both counseling and medication. This led to 6-month abstinence rates of 13% in the treatment group versus 4.1% in the control group (OR=3.5; 95% CI, 1.99–6.15). Patients who were directed to and enrolled in treatment programs were therefore more likely to attempt to quit and remain abstinent for up to 6 months.

Web-based programs offer reminders

Like quitlines, Web-based programs offer smokers immediate feedback to help them quit. Many of the programs include links to quitting resources, stories from former smokers and cancer patients, live advice from counselors, and message boards (TABLE 1). Web-based programs have been shown to help improve quit rates.

One study compared two Web programs involving 11,969 smokers.11 This RCT looked at an interactive program based, in part, on the AHRQ treatment guidelines. This program generates personalized letters for the participants along with monthly e-mail reminders. A modified program, developed by a maker of NRT products, served as the control; it contained more information about nicotine than about tobacco dependence and cessation. This program was also shorter than the interactive program, which was designed to assist smoking cessation.

Both programs improved quit rates: 10.9% for the interactive program and 8% for the modified/control program, compared with 3.3% for no treatment at all. Although this study was based on participant reports of abstinence over the previous 7 days, and had low followup rates (which Internet studies tend to have), the interactive program produced one more quitter for every 26 participants than the modified (control) program did, according to an intent-to-treat analysis (14.6% vs 10.7%, P<.001; OR=1.43; 95% CI, 1.28–1.59).

Another RCT looked at the use of a more extensive Web site, combining video, audio, and text.12 This program was fully automated and delivered entirely by computer. Again, using the AHRQ guidelines and other sources, researchers designed a series of five modules to simulate work with a live counselor. There were 13 different versions to match the demographics of the participant. The modules ended with a “quit calendar” for use by the participant to pick a date within the next 30 days. The program included 20 hours of video, although no participant saw every section. The intent-to-treat analysis showed a significant difference between groups: 12.3% in the treatment group versus 5% in the control group (OR=2.66; 95% CI, 1.18–5.99).


Web-based support helps smokers quit Boston University School of Public Health

Personalized quit plans American Lung Association

“Freedom from smoking” modules to guide smokers through quit process Privately supported

Support for “cold turkey” quitting Massachusetts Department of Public Health

Personalized “Quit Wizard” program

Text messages work

A short but interesting study used text messaging to target younger smokers in New Zealand.13 This RCT involved 1,705 smokers who had cell phones with text messaging. Researchers sent participants up to five messages daily around their quit date, drawing from over 100 messages that could be personalized with individual names/nicknames. The quit rate doubled 6 weeks out (28% vs 13%; relative risk=2.2; 95% CI, 1.79–2.70).

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