A Roadmap for Tobacco Cessation Treatment
April 1, 2020
AUTHORS
Cynthia Sheppard Solomon, BSPharm, RPh, FASCP, CTTS, NCTTP, Clinical Assistant Professor, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH
Dean Bricker, MD, Associate Professor, Chief, Division of General Internal Medicine, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH
Glen D. Solomon, MD, MACP, CTTS, NCTTP, Professor and Chair, Department of Internal Medicine and Neurology, Wright State University Boonshoft School of Medicine, Dayton, OH
PEER REVIEWER
William Elliott, MD, FACP, Assistant Clinical Professor of Medicine, University of California, San Francisco
EXECUTIVE SUMMARY
Tobacco use remains the greatest preventable cause of disease and premature death in the United States, killing 500,000 people each year.
- Recent figures show that as many as 70% of smokers want to quit and half have made a quit attempt in the past year, with most being unsuccessful. Yet, more than 40% of adults who smoke do not receive advice to quit from a healthcare professional.
- The three key hurdles to quitting are: 1) the physical addiction; 2) the psychosocial environment; and 3) the psychological/behavioral habituation.
- State telephone quit lines, often with the number 1-800-QUIT-NOW, are of variable consistency and applicability to all smokers.
- A brief encounter for tobacco use disorder (TUD) consists of three steps: ask, advise, and arrange.
- More intensive TUD interventions include a more comprehensive, five-step approach.
- Motivational interviewing is a useful approach to encourage patients to change behavior.
In the United States, about 500,000 people die each year from tobacco-related illness.1 These unnecessary deaths eclipse the numbers dying from opiate prescription drug overdoses by a factor of 10.2 Both are crises requiring the clinician’s full attention. Although tobacco use has decreased in recent years, its devastation continues to plague many, especially those marginalized by social or health disparities.3 It is with these patients that tobacco use disorder (TUD) finds most of its victims, including the uninsured, the impoverished, and those with lower education levels.
As the single greatest preventable cause of disease and premature death in the United States, tobacco use,4 along with hypertension and obesity, leads the list of modifiable cardiovascular risk factors. In Smoking Cessation: A Report of the Surgeon General, the Surgeon General calls on healthcare professionals to put an end to the staggering, completely preventable human and financial tolls that smoking takes on our country.5 Yet, a recent summary in the Journal of the American Medical Association6 highlights the lack of public health messaging about tobacco in social media posts and in the news. This underrepresentation suggests a need to alert consumers to the overriding harms and risks associated with tobacco and alternative tobacco, such as hookah and electronic cigarettes (e-cigarettes). Recent clinical observations document the benefits of using tobacco-specific wall posters in medical offices to trigger patient discussions about quitting.
This article serves as a resource for clinicians to use as a roadmap to successful evidence-based TUD treatment. In 2009, when tobacco became regulated as a drug by the Food and Drug Administration (FDA), there was no uproar from medical communities surrounding its re-classification. Physicians, as a group, had never received formal training about tobacco, since it was not previously considered a drug. In the past decade, medical schools have not dramatically changed their core curriculum to incorporate tobacco use or its harms, leaving a gap in education on the fundamental techniques required to sustain smoking cessation. This is one reason why tobacco-related illness continues to break records in numbers of people dying, in chronic illness created by its use, and in costs to employers per smoker nearing $6,000 per year.7 The Surgeon General’s 2020 report clearly states that more than 40% of adults who smoke do not receive advice to quit from a healthcare professional,5 reinforcing the need for the medical community to realign its priorities.
For the sake of discussion, alternative tobacco is generally considered to be under the tobacco umbrella. The term “tobacco” in this article accounts for all tobacco-like products, even though risks and benefits differ to some degree. One of the most important actions patients can take to improve their health is to quit smoking.5
Case: Steve, a 25-Year Smoker
Steve has been a smoker for 25 years and currently is smoking two packs a day. He started smoking in high school. He starts his day with a cigarette or two within the first few minutes of awakening. He says it haunts him all through the day. Like many smokers, he has not really enjoyed smoking for years, but he cannot wait to get in the car for his 45-minute drive to work to smoke another four or five cigarettes before he walks into his workplace. This often is the only time he will not be reminded of not being allowed to smoke in his workspace. His wife smokes, although not as much as Steve. He loves to have the gang over to watch all kinds of sports. They often hang out until late in the night, having a few beers and talking sports after the game. A lot of smoking occurs when his buddies are together. His kids complain to him about coming home to a house smelling like cigarettes. He worries about what he would do if he was not smoking; he could not give up the fun times and camaraderie. Six months ago, he thought about cutting back on smoking because he coughs so much, but it was too hard. His doctor told him to stop smoking about 18 months ago, but that was the extent of their conversation. “It just isn’t easy to quit,” he says.
Tobacco Screening
Current guidelines from numerous organizations suggest every patient should undergo tobacco screening during every visit.
Clinicians sometimes have interpreted this to be, “Do you smoke, yes or no?” Although this is a good beginning for discussion, getting more details about whether the patient has ever smoked, what types of products the patient has used, what other alternative tobacco products have been in the mix, and if there is a pattern can lead to a more thorough evaluation.
Patients may not recognize they are tobacco users, making it particularly important that clinicians be able to recognize some of the jargon used in describing various products. For example, many high school- and college-age young adults may visit hookah lounges regularly, not realizing the water pipes used to consume hookah often contain a molasses-sweetened tobacco mixed with charcoal, carrying a higher carbon monoxide content than tobacco cigarettes. There are multiple product types these days, from snus, a trendy form of chewing tobacco, to individually created options for vaping — often in the news for vaping-related health problems.
If patients are using tobacco, screening should identify how much they currently are using (packs per day), along with how long they have been using, calculating their “pack year” history.8 By using one of several nicotine dependency measures,9 the clinician can obtain an accurate picture of the patient’s potential difficulties in quitting smoking due to their nicotine dependence. Simple answers to questions, such as the number of cigarettes smoked each day, when (how soon after waking) cigarettes are smoked, which cigarettes are the most difficult to give up, whether the patient has difficulty not smoking when it is not allowed, and if a patient smokes when sick in bed, can approximate the patient’s reliance on nicotine. The assessment takes only seconds to calculate, and the clinician can ascertain the individual’s treatment requirements for a quit attempt. (See Table 1.) Since blood pressure is affected by tobacco use, blood pressure measurements should be documented as well.
Table 1. Assessing Nicotine Dependence While Taking a Tobacco History |
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Higher dependence may be associated with:
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Adapted from Dale LC, Ebbert JO, Hays JT, Hurt RD. Treatment of nicotine dependence. Mayo Clin Proc 2000;75:1311-1316. |
If patients say they currently are not using a tobacco or an alternative tobacco product, ask about their history, since they may have quit recently or may be living in an environment where secondhand smoke is a concern. Help the patient understand the risks of exposure — as much as 10% of tobacco-related deaths each year are directly related to passive exposure.5
General Considerations
If a primary care practice is not able to provide complete tobacco treatment services, but can handle brief interventions, referrals to other specialty practices or organizations can provide intensive interventions. Primary care practices can link to those offering evidence-based group counseling, digital services, or individual support, such as in a pharmacy, a clinic, a health department, or other regional practice. The clinician must preview and evaluate the list of potential referrals to ensure they are indeed providing evidence-based TUD treatment.10 This is key, as there are many practices advertising smoking cessation services, but not fully considering which treatment combinations and what methods lead to optimum successful quits. If no good choices for referral exist in the community, a clinical team can, with some training, be created within a primary care practice. Developing a team, to include the receptionist and medical assistant, as well as nurses, physician assistants, and pharmacists (in-house or within the outlying community), trained to collect tobacco history forms, to collect nicotine dependence data, and to provide support, can ease the practice into practical intensive interventions.
Choosing how to quit makes a huge difference for smokers. Success rates are highest when cessation medications and behavior modification support are combined for an adequate period of time. Recent figures show that as many as 70% of smokers want to quit; and, in the past year, 50% will have made a quit attempt. Unfortunately, most of those quit attempts will not be successful. The three key hurdles are: 1) the physical addiction to nicotine (nicotine dependence); 2) the psychosocial environment the smoker is living and interacting in; and 3) the difficulty in overcoming the psychological or behavioral habituation. With adequate healthcare support, these barriers can be overcome. The clinician must be ready to treat the nicotine dependence by prescribing the proper dosage combination of cessation medications while understanding and adequately counseling the patient on the psychosocial and behavioral interventions that must occur for a successful quit.
Components of Evidence-Based Tobacco Treatment
Evidence-based treatments include one or more FDA-approved cessation medications chosen based on a patient’s individual circumstances, symptoms, nicotine dependence, previous quits, and comorbidities, along with specifically directed behavioral counseling to combat the habits and triggers of tobacco use and dependence. Appropriately used, this combination of modalities greatly improves the chances that quit attempts result in long-term abstinence.11
To provide evidence-based tobacco treatment, the clinician should receive formal training, demonstrating proficiency to implement individualized treatment modalities for an adequate period of time. Mastering specialized training for certification as a tobacco treatment specialist (CTTS)12, 13 allows clinicians to sit for the exam to achieve national certification in tobacco treatment practice (NCTTP). In a tobacco treatment practice in a clinic or hospital, there usually would be other healthcare professionals on staff, perhaps respiratory technicians or others, referred to as tobacco treatment specialists (TTS), with some training but without national certification.
When evidence-based TUD treatment is delivered, the patient is evaluated appropriately for comorbidities, current medication use, and nicotine dependence. Clinicians need to be aware of potential drug interactions, with nicotine as well as with tobacco smoke. (See Table 2.) Patients with comorbidities frequently receive prescriptions for numerous medications. Discontinuing tobacco may require adjusting current levels of daily medications, since cytochrome P450 interactions occur commonly with tobacco smoke. The clinician needs to be watchful and proactive in managing the changing medication levels. When specialty tobacco clinics care for new patients not seeing primary care clinicians, it is not uncommon to find uncontrolled hypertension.
The patient can be served best by using insurance coverage or other beneficial patient-focused programs to keep the costs of treatment to a minimum. Individualized care usually includes one or more of the seven FDA-approved tobacco cessation medications (unless the patient is either pregnant, an adolescent, or a light smoker), along with counseling support (either group, individual, or phone) for cravings, triggers, and coping techniques.
The specialty tobacco practice should provide primary care clinicians with regular updates on how the patient’s care is progressing. This coordination should occur throughout the term of the extended quit period. Primary care clinicians should encourage the patient’s quit attempt as they follow up with them throughout the weeks and months of extended quits.
Primary care practices can offer these same comprehensive approaches quite effectively. Incorporating various members of the clinical team, including office personnel, demonstrates greater efficacy for patients, since they feel comfortable sharing their desire to quit, and benefit by active positive support. Once adapted, encouragement, support, and successful evidence-based individualized approaches can be a source of best practice to reduce morbidity and mortality. Primary care clinicians do not need to provide all the services on their own. For example, the counseling portion of services can be provided in part through digital, phone, or group sessions in the neighborhood, at a community pharmacy, or at a clinic.
Understanding State-Specific Phone Quit Lines
Telephone quit lines are one of several options for creative assistance in supporting cessation medication adherence and providing behavioral counseling to patients who want to quit smoking. The Centers for Disease Control and Prevention, the American Lung Association, and others promote telephone-based tobacco cessation services for all, often with the phone number 1-800-QUIT NOW. Unfortunately, these services are not always free to everyone, and one must identify in each state who is eligible for free access. Barriers can exist, and include requiring the smoker to be part of a larger organization or insurance group. Historically, this has been an obstacle for people trying to quit on their own. Although Medicaid recipients should be able to access this resource free of charge, it is best to clarify with the Medicaid insurer prior to the patient’s attempt to access this important service. Patients who want to quit need to have reliable options, such as these counseling services. Not all quit lines provide treatment and counseling that is evidence-based. Some states do not offer patients all the approved medication options or behavioral approaches. Clinicians need to look for local resources that meet the guidelines of evidence-based treatment. Offering one cessation medication to all is not as helpful or effective as providing the individualized approach. For more information on quit lines, visit www.cdc.gov or www.smokefree.gov. (See Table 3.)
Table 3. Tobacco Roadmap Tools and Resources |
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Website |
Resources Available |
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Provides patient information, cases, and tips from former smokers, basic concepts for healthcare professionals, and wall posters |
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Provides cases, information on reimbursement, including the 2018 Billing Guide for Tobacco Screening and Cessation, and information on state and federal tobacco cessation coverage |
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A resource for quitting that offers text reminders and assistance with quit plans |
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Provides several comprehensive courses for general knowledge/proficiency and for training the trainer, and includes resources for incorporating programming into curricula |
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Additional help for healthcare professionals is available from the Centers for Disease Control and Prevention: “Healthcare Providers: Tools and Resources,” available at https://www.cdc.gov/tobacco/campaign/tips/partners/health/hcp/index.html |
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Providing TUD Interventions
Determining the most appropriate path at each visit, either by brief or intensive intervention, depends on skills and level of service in that clinician’s practice setting. Although brief interventions, requiring three to 10 minutes, are promoted for primary care settings, it is not only reasonable but realistic for the primary care clinician also to perform intensive interventions of greater than 10 minutes. Barring that, the provider can collect basic information, provide initial advice, and connect the patient to other healthcare professionals capable of providing the necessary steps to successful quits. This does not circumvent following up regularly with the patient and providing encouragement and support. Being able to converse comfortably with the smoker regarding best practices for TUD and offering select suggestions for supporting the quit is critical.
The Brief TUD Approach
A brief encounter consists of three steps, including ask, advise, and arrange. Choosing this approach does not absolve the clinician from providing two other additional steps — assess and assist — in support of the patient. Choosing a priority issue for each visit and scheduling the patient for a follow-up visit to address each step on the tobacco roadmap is needed in an evidence-based approach.
Engaging other team members, either in the community or within the practice (pharmacists, nurses, physician assistants), will help improve outcomes. By triaging evidence-based tobacco treatment resources in the surrounding community and having referral lists readily accessible, counseling support will be available to continue after making the initial assessment of possible pharmacologic treatment. Always follow up with the patient about referrals. Timely continued patient support has been shown to improve success when healthcare professionals work together on cessation counseling and problem-solving. By taking into consideration ongoing nicotine dependence, previous quit successes and failures (including what methods and products were used), triggers, cravings, general coping mechanisms, and acute nicotine withdrawal, success is more likely. Clinicians should document all aspects of data collection and evaluation.
Ask about current use of tobacco at every visit and document data collected. If the patient answers yes, clearly and in a strong, personal way, advise the patient to quit, giving them specific reasons. Advising a patient to quit should not be making the statement, “I want you to quit now!” Instead, initiating a conversation regarding why it is not good to continue smoking or using tobacco is more likely to set up a positive interaction. Perhaps the patient has a new grandchild and could benefit by being reminded they will want to play with, carry, and care for the baby as he or she grows, and right now they are struggling to do daily exercise, with extensive shortness of breath.
If the patient answers no when asked if he or she uses tobacco, clarify whether the patient has ever used tobacco, and if so, did they recently quit? Remember that patients, at times, do not realize the products they use may contain nicotine and/or tobacco. If they quit recently, it is important to ask about the patient’s current tobacco status, since they may still be vaping e-cigarettes, or using other noncombustible tobacco products. The clinician often can provide support, identify challenges, and discuss relevant medication use.
Arrange for follow-up with a practitioner who provides evidence-based tobacco treatment if you cannot provide an intensive intervention at this point. Sending relevant information, including estimates of the patient’s level of nicotine dependence, and information accumulated on what quit attempts previously have been made, with which products, and why there was a failure, can be very helpful to the specialist or organization you are involving. The benefit of staying in touch with the patient as they move toward a quit will be helpful as well. Following up is part of the continuity piece, and should be a combined goal for the clinician and the patient, with any other organization or specialty person also involved. Continuity of care reduces unsuccessful quits.
Intensive TUD Interventions
All five steps listed here allow for an effective intensive approach when the clinician feels confident managing both the pharmacologic and behavioral counseling arms of evidence-based treatment.14
1. Ask about tobacco screening at each visit. Be sure to include more than just a “yes” or “no” response regarding use. For efficiency, a tobacco history form measuring dependence9 can be provided and discussed with patients at appointment check-in. The FagerstrÖm Test for Nicotine Dependence9 and other measures (see Table 1) can be used to collect necessary information to assist clinical decision making. Document each encounter, confirming the patient’s responses. Nicotine dependence and other special needs can be assessed quickly once the clinician and patient speak, determining whether quit attempts already have occurred and what the patient’s actual experience was with that quit attempt. Identifying why a previous quit attempt went wrong is a key triage point. If a patch regularly fell off during a previous quit attempt because the patient worked outside in the heat of summer days, or if a smoker has not used nicotine replacement gum properly15 — swallowing the liquid created by chewing it vs. “parking” it in the cheek after briefly chewing the gum until tingling is felt — the clinician can determine adequate alternatives for this new quit attempt, communicating clearly the benefit of keeping in touch to manage unrecognized challenges as they occur.
2. Advise the patient to quit by offering them a personal message focused on issues of special concern for them. Help the patient feel connected to a particular benefit or goal that may be especially pertinent to them. The American Cancer Society offers an online timeline of “Benefits of Quitting Smoking Over Time,” found at https://www.cancer.org/healthy/stay-away-from-tobacco/benefits-of-quitting-smoking-over-time.html. This list of benefits highlights the effects of the body’s healing, promoting that it is never too late to quit using tobacco.
3. Assess the patient’s current interest in quitting. By using a quit scale, clinicians can readily determine the patient’s willingness to attempt a quit, and converse about developing an action plan for that quit.16 Using a simple 1-10 scale, with 10 being the strongest desire, patients can mark their level of commitment or lack of desire to quit. If the scale shows a 7 or greater, the clinician can be sure the patient is serious about the desire to develop an action plan and choose a quit date. An ambiguous patient, though, may not be prepared to pick an actual quit date or even contemplate quitting in a serious way. Through motivational interviewing (MI) (see Table 4), the clinician may help the patient move through the early phases of contemplation more rapidly, and become more determined. The MI style is detailed later in this article.
Table 4. Motivational Interviewing |
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When you feel stuck: |
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Adapted from Hershberger PJ, Bricker DA. Who determines physician effectiveness? JAMA 2014;312:2613-2614. |
4. Assist the patient in developing an individualized quit “action plan,” allowing the patient to pin down their own quit date. Be prepared to offer ideas for things to consider prior to that date, such as cleaning a car to remove smoking odors and thinking through social issues related to the effects of the habit. At this point, options for pharmacologic intervention should be determined, based on nicotine dependence and comorbidities (Table 5), calculating an adequate time period for initial medication use. Individualize medications, educating the patient on appropriate use. Communicating on these topics adequately can make or break a quit attempt. Some medications require one to two weeks of use before the scheduled quit date for greatest success. Quit handbooks and specific directions also can be individualized. Resources, including digital applications, phone quit lines, group and individual classes, and support groups for tobacco users have a role in successful treatment. Tagging a trained clinical team member to touch base with each patient by phone on a weekly basis can increase the chance of success. When more than one healthcare professional is involved in a patient’s TUD care, success rates go up.
5. Arrange follow-up, including counseling services that have been booked and scheduled. Provide a return visit with the clinician for continued care. Prepare a resource sheet or list of helpful tips and tools, if possible. Plan to communicate with all partners in the care team, whether other team members in the practice are playing a significant role or if another specialty practice will be involved.
Helping Patients Recognize the Health Implications of Smoking
Nicotine withdrawal usually is short-lived, starting quickly when the quit attempt is made and lasting two to four weeks. Anxiety and irritability, including excessive anger and frustration, can last three to four weeks or more. Depression can last a month, and often is dependent on other substance use, such as alcohol or recreational drugs. Lack of ability to concentrate, not sleeping well, and feeling restless are all possible symptoms. Weight gain due to increased appetite is predictable, and is considered part of the initial nicotine withdrawal, with an average of 5-9 pounds gained in the first year of a quit.17 Helping patients identify how to pre-plan low-fat, healthy snacks and add an exercise regimen helps them consider their long-term health, as they evaluate the risks of continuing to smoke vs. adding a few pounds. Neighborhood malls often offer early morning openings to accommodate walkers before shopping begins.
Nicotine dependence and withdrawal have physical and psychological implications. Patients need to be able to relate to the expectations of these conditions. Whether cancers, cataracts, hearing and vision deficits, bone-related conditions, aging skin, effects during pregnancy, or general illness and impairment, quitting tobacco saves the patient from many ailments. In addition, thousands of dollars can be saved in a successful long-term quit. These topics and those related to risks to family and the effects of secondhand smoke all are significant areas of conversation. Count on the patient wanting to hear what benefits of quitting will accrue: Within 24 hours, carbon monoxide blood levels go to zero, with other risks decreasing dramatically over time. Choosing several long-term benefits to highlight during each office visit can build enthusiasm when the patient realizes the overall impact of a better future. See “Benefits of Quitting Smoking Over Time” at www.cancer.org.18
Cognitive Behavioral Issue Counseling
Some healthcare professionals believe cessation medications alone can be the answer for smokers. Unfortunately, this is one reason many quit attempts are unsuccessful. Without accounting for the individual triggers, cravings, coping abilities, and general motivations involved with the tobacco habit, it is difficult for a quit attempt to be successful, even when adequate pharmacotherapy is in place. Some have said tobacco use is a “learned addiction,” meaning the physical dependence is combined with the habits instilled by the tobacco use.19 Triggers or cues are in place and must be recognized to overcome them. They can be short-term or long-term issues. The smoker’s living environment also is a vulnerability. If their significant other is a smoker or prefers to have the smoker smoking, hurdles increase for the quit attempt. The smoker needs emotional support from friends and loved ones during this challenging time. Learning how to change patterns of behavior and asking family and friends for support, especially when old routines are not followed, affects the quit attempt positively.
Cravings and Triggers
To prepare for a quit attempt, the smoker can get ahead of impulses that surely will spark stress, bringing on urges during the weeks and months ahead. Learning to tell the difference between the physical pull of nicotine and the sensory draw of the smoking habit can affect the experience positively. The smoker will need to get rid of all cigarettes, wash ashtrays, and remove lighters. After selecting the quit date and removing all the cigarette paraphernalia, the goal is to quit upon awakening. Patients need to set the date for themselves. Clinicians should not set quit dates for patients.
Coping Mechanisms
Journaling about tobacco use can be helpful. Identifying when and why one chooses to have a cigarette can be enlightening and allows a smoker to think through how to manage difficult urges in the upcoming weeks. Having plans for difficult situations will reduce relapse opportunities. Making a list of the top three or four urges20 — powerful triggers that can be predictive — provides a heads-up in preparation. Contemplating how to manage expectations can lay the foundation for smooth responses when the urges occur. For example, if the smoker usually smokes several cigarettes on the drive to work, having pre-cut vegetables, such as celery, broccoli, and carrots, to hold and eat — reinforcing the hand-to-mouth gesture — can reduce the stress of not smoking. The car, freshly cleaned, without the smell of smoke, is an example of the kind of details required to reduce obstacles to success.
Nicotine Dependence Estimates Physical Addiction
One quick way to estimate the patient’s dependence on nicotine is the Fagerstrom Test for Nicotine Dependence (www.ndri.curtin.edu.au/btitp/documents/Fagerstrom_test.pdf), focusing special attention on when the patient chooses to smoke. Looking at the time to first cigarette in the morning and other measures identifying when the patient feels a special need to smoke determines a fairly accurate estimation of the level of dependence on nicotine, both physically and psychologically. This extrapolates into how to choose the dose and specific pharmacologic product(s) necessary to cover 24 hours. The more the patient chooses to smoke early in the day or smokes in inappropriate settings, the greater the chance the patient has a high level of dependence. Removing nicotine from someone heavily dependent requires an appropriately effective amount of nicotine replacement, with other treatments chosen properly for the patient’s lifestyle, addiction, and comorbidities.
Studies looking at the benefits to patients of buying their own over-the-counter (OTC) nicotine replacement products, without having adequate counseling advice and proper assessment of dependence from a healthcare professional, show low percentages of patients finding long-term abstinence possible. Using OTC nicotine replacement products purchased and used by the smoker without counseling reduces abstinence rates below those achieved by the patient quitting cold turkey on their own.21
Essential to making pharmacological choices for a particular situation is the strategy of following evidence-based treatment parameters. With high dependence comes the need for higher amounts of pharmacologic support, perhaps including more than one form of nicotine replacement or nicotine replacement in combination with one of the two other FDA-approved medications. The patient using 10 cigarettes or less per day may require, for example, a lower-dose nicotine replacement patch for a successful quit attempt (Table 5) vs. the dose needed for a smoker of two packs per day.
Pregnant patients and adolescents fall into a different category, where pharmacologic treatment may not be appropriate in lieu of behavior counseling and therapy.
The smoker should be provided a realistic dosage regimen. When nicotine dependence is high, a combination of products, including either two different nicotine replacement products of different onsets of activity and durations, or one nicotine replacement product with another FDA-approved cessation medication (Table 5) should be considered. Not only will having adequate nicotine replacement be helpful, but having a second product for acute withdrawal or overwhelming urges can be essential.
Both bupropion and varenicline are most effective when administered a week or two ahead of the quit date to allow the medications to reach effective, steady state levels. Verifying appropriate candidates for each medication leads to greater adherence, along with counseling them about safe, effective use. For example, children and pets can be poisoned if the medications are easily accessible and not safely stored away.
Use of Other Concomitant Substances
It is fairly common to find caffeine and alcohol use may affect both the smoking experience and quitting. Taking a proper tobacco history along with the history of substance abuse can open doors to better outcomes. Research now supports that all recreational substances the patient may be using and/or abusing should be included in the quit.22
Maximizing Positive Emotions
By considering deep breathing, finding new ways to exercise, and eating healthy foods, the patient can maximize their action plan as a lifechanging growth opportunity. Whatever already works for managing emotional tensions can be reinforced. Practicing positive approaches and considering suggestions in group counseling add to the available options. The support from group counseling can increase a patient’s exposure to new ideas. The woman who reaches for knitting needles instead of a cigarette can share her success with other group members. The primary care practice can offer deep-breathing lessons for the group to learn how to take slow, regular breaths, counting out on the exhale, and thinking about positive images for 5-10 minutes several times during the day.
Benefits of Finding Alternative Solutions to Difficult Situations
When patients can recognize helpful solutions, changing long-term patterns and behaviors, they often surprise friends and relatives. Clear, concise communication with loved ones sets the stage to do things differently. As time goes on, problematic situations should lessen.
Unique problems will come up; reviewing the many possible scenarios reduces unexpected stress during these difficult times. As a nonsmoker, the patient will need to acquire a nonsmoker’s approach. They, too, have the right not to be exposed to tobacco smoke or smoking behaviors. During a quit, this is especially important, since the smell of smoke can be a trigger.
Lapses and relapses occur. Be ready to address mistakes and setbacks, as they surely will occur. While it is upsetting, having a strategy for what to do when it occurs will reduce complications. The patient needs to continue moving forward. Together, the clinician and patient can manage whatever arises as the patient continues through their quit.
Smokers Not Ready to Quit
MI, assisting the individual in changing his or her perception of consequences and ultimately changing behavior,23 is a useful approach to encourage patients to change behavior. MI (see Table 3) is a collaborative conversation style aimed at strengthening a patient’s own motivation and commitment to change (quit smoking).24 Patients do not want to be judged or lectured;25 thus, the MI approach seeks to replace the common practice of educate (“Let me tell you about all the harms of smoking”) and advise (“You need to stop smoking”). The MI approach emphasizes understanding circumstances from the patient’s point of view (“If it’s OK with you, I’d like to hear more about your smoking … ”), focusing on what matters most to the patient (“What factors seem to be associated with the most emotion?”). It also highlights the patient’s ambivalence to quitting (“What do you like about smoking? What aspects don’t you like?”).
Although MI is not a strict formula or technique but rather a style of conversing, there are key concepts to keep in mind.24 Change is driven by the desire for consistency between goals/values and the patient’s behavior. Enhancing desire for change can be promoted by developing discrepancy (listening for the “buts”: “I really should quit smoking, but I’m just under too much stress right now”) and attending to emotion (“I really want to be able to … ”). While knowledge is necessary, it typically is insufficient to drive change.26 Consequently, informing should be done at the patient’s request or with their permission, and only after first eliciting what the patient already knows. (“What is your understanding of how smoking affects your heart?” or “If it’s OK with you, I can explain how smoking can lead to a heart attack.”)
It also is important for providers to consider who is doing the work. The provider’s work includes making diagnoses, determining treatment options, etc., while the patient’s work includes decisions about treatment options, adherence, and health behaviors (quitting smoking). MI is an approach to conversations about patient work.27 Relevant MI skills include using:
Open-ended questions: Questions that cannot be answered with a simple yes or no (“What connection do you see between your smoking and your recent bronchitis?” instead of “Do you see a connection between your smoking and your recent bronchitis?”)
Affirmations: Statements that accentuate positive behavior (“You certainly have been persistent in your repeated attempts to quit.”)
Reflective listening: Statements that summarize what the patient has said or that make a guess about the meaning of what they are expressing (“You seem very concerned about developing the need for supplemental oxygen.”)
Summarizing: Combining several reflections with the intent to draw together the patient’s concerns, motivations, intentions, and/or plans.
0-10 scales: A scale used to assess importance, readiness to change, confidence, etc. (“On a scale of 1-10, with 0 being not ready and 10 being ready right now, how ready are you to consider a quit-smoking attempt? What made you say 4 instead of 2? What would it take for you to move to a 5 or 6?”)
While many consider MI a best practice for cessation counseling, a recent review cautions that the quality of available evidence limits conclusions about whether the MI approach is superior to brief advice or usual care provided in most clinical settings.28,29 MI may be thought of as a tool to encourage patients to seek help quitting rather than a primary tool for cessation counseling. Once a patient enters treatment, MI is useful as an approach to manage transient ambivalence about quitting and enhance motivation for specific tasks (cleaning curtains, hiding cigarettes and ashtrays).
Where Do Alternative Tobacco Products Fit In?
In 2016, alternative tobacco products, such as e-cigarettes, hookahs, and cigars, and chewing products such as snus, came under FDA jurisdiction.
High numbers of young users now are moving to e-cigarettes. And, for the first time in decades, tobacco cigarettes are not the first product of choice for young people. However, the American Academy of Pediatrics Committee on Substance Use and Prevention, in the January 2017 issue of Pediatrics, warned of new research finding that the earlier in life a person is exposed to nicotine, the less likely they will be able to quit using tobacco and the more likely they will consume increasingly greater quantities.30 They also raised the point showing youth require more quit attempts than adults before they successfully quit tobacco. And, in most cases, it requires a decade or more of use before young people will make a serious quit attempt.
Within a year or two of starting an e-cigarette habit, about 33% of young vapers will convert to dual use due to the powerful addictive force of nicotine.31 The original concept of the e-cigarette was created less than two decades ago. Yet, the ease of access, the novelty, and the assumption of minimal risk associated with vaping has made its use skyrocket, especially in the young. Research has shown serious hazards associated with heating chemical propellants, such as propylene glycol and glycerin — ingredients found in antifreeze — in the electronic nicotine delivery system (ENDS) for conversion of liquid nicotine to a gas for inhalation. Formaldehyde-like substances are created and can be found in the lungs of vapers. Flavors — such as diacetyl, associated with the smell of butter-flavored popcorn — also have been associated with harm when heated. When microwave popcorn factory workers first reported respiratory illness after breathing diacetyl in their workplace many years ago, patients presented with irreversible respiratory illness. Bronchiolitis obliterans was diagnosed32,33 in several of these employees, leading to the use of respirators in the factory to reduce or eliminate employee exposure.
Numerous e-cigarette flavorings are generally recognized as safe (GRAS) when eaten in small quantities in food. But most have never been tested as inhalants in the high heat, third- and fourth-generation, tank-like ENDS being sold currently.
In 2016, the FDA set the goal to provide a two-year window for manufacturers to submit safety data for full market approval. Those parameters changed with the new administration, pushing the safety data collection back several more years. To date, these data remain uncollected, reducing the overall ability to evaluate harm associated with this group of products. Recent reports of multiple vape-related illnesses now suggest cutting agents, such as vitamin E acetate, may create additional risks in some products. Without safety and efficacy data, key indicators of risk remain unclarified.
There is no current evidence that any alternative tobacco products can be considered safe, efficacious harm reducers for tobacco cessation. A recent study shows participants were likely to continue using e-cigarettes for as long as a year when e-cigarettes were used to replace tobacco cigarettes in a quit attempt.34
Hookah also has become a frequent choice of young people in the past several years. With 23% of high schoolers self-reporting hookah use in the past 12 months, clinicians and parents need to be aware of its numerous risks. Hookah is molasses-laced tobacco over heated charcoal in a water pipe. Young people often do not realize it is a tobacco product, nor do they realize it is more harmful, puff for puff, than tobacco cigarettes. As state and federal laws regulate more smoke-free public spaces, many hookah lounges have found ways to be exempted from tobacco laws, including offering clients the opportunity to rent hookah paraphernalia, without the need to purchase tobacco, so lounge operations are not categorized as tobacco retailers. Healthcare professionals, working with community leaders, can raise awareness of the infectious disease and respiratory illnesses associated with passing the water pipe from person to person during a smoking session. With carbon monoxide levels five times what is created in a similar amount of time with tobacco cigarettes,35 hookah regulations need to protect vulnerable young adults. College students, assuming a low health risk, often seek out hookah lounges for social time with friends.
Case: What Are the Hurdles for Steve?
Steve’s house probably smells of smoke. He smokes in the bedroom, where curtains, bedding, and pillows probably are coated heavily with tobacco smoke. His car smells of smoke, and he smells of smoke. Before anyone quits, it all must be cleaned and cleared out. Routines must be adjusted, or success will be that much more difficult. Not only Steve’s significant level of nicotine dependence — smoking two packs a day — but his entire lifestyle has been infiltrated by this habit, this dependence. It is a lot to overcome, especially without optimum treatment choices. Steve needs professional support to move toward wanting to attempt a successful quit. He needs help to start an action plan, and he needs to know someone will support him through this difficult process. His kids are not happy with his smoking, and he knows his cough is not normal, but his doctor was so judgmental. He was not given any treatment options. His physician may not have felt equipped to assist Steve. Steve’s thoughts of quitting, of taking on this huge task, went out the window.
An action plan, designed by Steve, with the help of a healthcare professional, could establish ways for Steve to begin to think through managing his life as he tries to quit. His wife smokes, but not as much as he does. Maybe they can try to quit together. He will have to rethink his buddies coming over to his house for sports. And what will he do for the 45-minute drive to work? Conversations with a counselor, whether the primary care clinician, pharmacist, or some other person on the team, will include finding options for Steve. Can he eat carrots as he drives, using the “hand-to-mouth” motion, or trigger, he is used to, or could he use a cinnamon-flavored toothpick to keep his hands busy? Providing options for Steve, ways to prepare for the difficult first days of his quit, will make a difference as he moves through a quit attempt.
Summary
Evidence-based tobacco treatment improves long-term outcomes. The impact extends to helping patients survive and even thrive as nonsmokers. David Satcher, former U.S. Surgeon General, said, “Starting today, every doctor, nurse, health plan, purchaser, and medical school in America should make treating tobacco dependence a top priority.”
The authors wish to thank the faculty, especially Thomas Payne, PhD, director of The ACT Center for Tobacco Treatment, Education and Research, part of the University of Mississippi Medical Center (UMMC) Cancer Institute at UMMC, for their skilled approach to teaching healthcare professionals about TUD. Many resources can be found in materials provided through UMMC.
References
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- Ohio State News. Study: Companies pay almost $6,000 extra per year for each employee who smokes. Published June 2, 2013. https://news.osu.edu/study-companies-pay-almost-6000-extra-per-year-for-each-employee-who-smokes/
- National Cancer Institute. NCI dictionary of cancer terms: Pack year definition. https://www.cancer.gov/publications/dictionaries/cancer-terms?expand=P
- Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. Br J Addict 1991;86:1119-1127.
- U.S. Preventive Services Task Force. Tobacco smoking cessation in adults, including pregnant women: Behavioral and pharmacotherapy interventions. Published September 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1?ds=1&s=tobacco
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- Sheffer CE, Payne T, Ostroff JS, Jolicoeur D. Increasing the quality and availability of evidence-based treatment for tobacco dependence through unified certification of tobacco treatment specialists. J Smok Cessat 2016;11:229-235.
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In the United States, about 500,000 people die each year from tobacco-related illness. Although tobacco use has decreased in recent years, its devastation continues to plague many, especially those marginalized by social or health disparities.
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