What is latest word on smoking cessation?
Nicotine replacement now standard of care
Question: One of our larger clients is on a big push to promote smoking cessation and wants our help. I’ve followed the issue fairly well over the years, but I’ve lost track of what is considered the best method to promote. Should we suggest making the nicotine patches or gum available along with the standard counseling?
Answer: Yes, nicotine replacement therapy is now considered an important adjunct to most smoking cessation plans.
The best consensus on smoking cessation is found in the guidelines issued recently by the Agency for Health Care Policy and Research (AHCPR), part of the U.S. Department of Health and Human Services in Washington, DC. The AHCPR guidelines recommend combining the most proven smoking cessation techniques, and the use of nicotine patches or nicotine gum is an important part of the plan.
Occupational health providers should take advantage of every opportunity to encourage patients to stop smoking, according to the guidelines. The effort should be much more than just a casual comment during an examination.
A more thorough, diligent effort at smoking cessation will come when insurers are more willing to pay for smoking cessation services and pharmacotherapy, the AHCPR report suggests. The agency strongly urges insurers to pay for those services now but says health care providers still should urge patients to stop smoking at every opportunity.
To determine the best approach to smoking cessation, the agency convened a panel of experts and reviewed more than 3,000 scientific articles. The investigation by the AHCPR found that these three treatment elements are especially effective in helping smokers quit:
• Nicotine replacement therapy.
The nicotine patch or nicotine gum can double the rate of success for smokers who want to quit.
• Social support.
Encouragement and support from the clinician just good, old-fashioned cheerleading can have a significant effect on the smoker.
• Skills training and problem solving.
Even when they are sincere about wanting to stop smoking, smokers often have a hard time adjusting to life as a nonsmoker. Health care providers can help by providing tips on how to get through the times of day when smoking is second nature and how to deal with the inevitable cravings.
More treatment means more success
The agency also found that there is a direct relationship between the intensity of treatment and the likelihood of success. Individual or group counseling programs are a good idea for many patients. The AHCPR recommends that counseling be delivered over four to seven sessions of 20 or 30 minutes each. The sessions should be spaced over at two weeks but preferably eight weeks.
While recommending that clinicians use a wide variety of approaches to help smokers quit, the AHCPR points out that not every smoking cessation technique will work. The agency looked at acupuncture, hypnosis, clonidine, antidepressants, and anxiolytics/benzodiazepines, but it concluded that there was no evidence showing their effectiveness.
The AHCPR made no recommendation on the use of nicotine nasal inhalers, recently approved for prescription use in the United States, saying not enough data exists to study.
Tips for health providers
The panel of experts also offered these suggestions for how health care providers can best help their patients quit smoking:
• Identify smokers by asking every patient at every visit if he or she smokes.
• Implement a tobacco-user identification system in your facility. This can be a recordkeeping system that flags the patient’s record to alert the physician that the patient is a smoker.
• Record the patient’s smoking status as a vital sign.
• Encourage smokers to quit at every opportunity.
• Ask smokers about their desire to quit and reinforce their intentions.
• Give motivational messages to those who are not ready to quit. Remind them that, when they decide to quit, you are eager to help them and can provide special assistance that will help them be successful. All they have to do is ask.
• Help motivated smokers set a quit date.
• Prescribe nicotine replacement therapy.
• Offer specific, practical advice about how to deal with life as a non-smoker, especially how to handle situations or emotional states that may cause relapse.
• Encourage relapsed smokers not to give up entirely and to try again.
[Editor’s note: The summary AHCPR publications are Smoking Cessation: Quick Reference Guide for Primary Care Clinicians; Smoking Cessation: Quick Reference Guide for Smoking Cessation Specialists; and You Can Quit Smoking, a patient’s guide. All are available free of charge from the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907-8547. Telephone: (800) 358-9295. The publications also are available by fax by calling (301) 594-2800.
For single and bulk copies of the full guideline, Smoking Cessation: Clinical Practice Guideline, contact the U.S. Government Printing Office at (202) 512-1800. The price varies according to quantity.]
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