Jump-Start Smoking Cessation
RB Watts MSa, Susan S. Hendrick PhDb
Correspondence to RB Watts MS. Email: Rb.watts@ttu.edu
SWRCCC 2014;2(6):49-51
doi: 10.12746/swrccc2014.0206.079
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Background
Smoking cessation is at the forefront of behavioral
agendas that physicians should have for their
patients. Although smoking prevalence has declined
overall in recent decades, smoking remains one of the
most preventable causes of illness and death. 1 Smoking
is linked to pulmonary diseases (e.g., COPD),
cardiovascular disease, several cancers, and multiple
other pathologic states as well. The illness burden
and the resulting economic burden, estimated at
$200 billion in healthcare costs and lost productivity,
make treatment of smoking a medical priority.
1
The US Department of Health and Human
Services (HHS) has published evidence-based guidelines
for the treatment of nicotine dependence2 The
logical place for implementation of these guidelines
(and briefer versions thereof) is in medical settings
that address patients’ general illness/wellness, most
frequently Internal Medicine or Family Medicine. And
even very brief intervention by a physician to target
a patient’s need for smoking cessation can increase
quit rates.
One important fact that patients need to be
told is that it is never too late to quit smoking. For
example, smoking cessation is useful for virtually any
patient with any type of cancer undergoing any treatment.
Outcomes of treatment tend to be better, longevity
may be increased, and quality of life is higher.3
The diagnosis of cancer or serious pulmonary or cardiovascular
disease can offer a physician a unique
“window of crisis” through which to introduce the idea
of reducing and ultimately ceasing to smoke, but the
medical-home physician does not want to wait until a
severe disease diagnosis. Earlier is better. As noted,
HHS offers extensive guidelines for smoking cessation
treatment, but sometimes less is more. For example,
a Memorial Sloan Kettering study found that
cessation counseling and pharmacotherapy were just
as effective as both of these combined with a novel
behavioral tapering intervention, when both treatment
strategies were used with newly diagnosed cancer
patients who smoked.4 Thus, two modalities were just
as effective as three.
Finding the “access point” of a smoker depends
on several factors, not limited to but including
a respectful and non-blaming physician who can offer
help in the form of pharmacotherapy, practical strategies,
and encouragement. In the case study that follows,
all these elements (plus an appropriate referral)
are provided.
Case
A 60-year-old male, “John,” with a history of
chronic obstructive pulmonary disease, hypertension,
and tobacco abuse (smoking) arrived in clinic for a
routine follow-up appointment. In previous visits, the
patient would quickly deny any desire to quit smoking
and would try to change the subject. However, John’s
COPD symptoms are worsening and his smoking
behavior is considered to be a primary contributing
factor. How could John’s physician address smoking
cessation in the clinic appointment?
Discussion
The following conversation between John and
his physician will demonstrate a typical and appropriate
brief smoking cessation intervention. This conversation
begins after discussing John’s worsening
COPD symptoms:
Physician: I’m told that you are still smoking. I
know we’ve talked about smoking in the past, and
you haven’t been interested in quitting, but I have
to say that I am starting to see signs that your
COPD is getting worse. Unfortunately, continuing
to smoke will most likely cause further problems
and make treatment very difficult. I must strongly
advise you again to think about quitting.
John: Yeah, I know. I’ve actually been trying to
cut back. I was smoking two packs a day, but I am
now down to around one.
P: That’s great! Cutting out any amount of cigarettes
is a move in the right direction. It sounds
like you’ve been taking the idea of quitting more
seriously. What reasons do you have to quit
smoking?
J: Well, I have also noticed my breathing becoming
more difficult, and I have been coughing a lot
more which has been scaring me a bit. I just had
a new granddaughter and I really want to make
sure I can be around in her life as much as possible.
P: I certainly want that for you as well. Quitting
smoking is a very tough thing to do, and if you’d
like, we can talk about some options we have
available to help you along.
J: Sure, I could really use some help.
At this point, John and his physician discuss options
regarding nicotine replacement therapies and smoking
cessation medications. Patients will vary in regards to
which medications or replacement therapies are appropriate.
J: OK, I think I’ll try out the nicotine patch, though
I don’t think I want to try Chantix.
P: Great, sounds like we have a plan. Also, if you
feel like you could use a little extra help before our
next visit, you can call 1-800-QUIT-NOW. They
can provide extra help and resources as you
try to quit. It’s important to take specific steps
to try to keep yourself from automatically grabbing
cigarettes through the day, and the people
at that number can help you.
J: OK, I’ll keep that in mind.
P: Excellent, I’m so happy that you are taking
these steps. I’d like to see you in three weeks.
Then, we can check in and see how things are
going. If you’re still having trouble, we can see
what other things we can do to help you quit.
In this brief intervention, the physician was
able to quickly address John’s smoking behaviors.
First, as is important with every tobacco- using
patient at every visit, the physician assessed
John’s current smoking behaviors. Following this,
the physician then advised John to quit smoking.
Though John had refused to consider smoking
cessation in the past, it became apparent in this
visit that he was beginning to feel motivated to
quit. Helping a patient quit smoking can sometimes
be a long-term process spanning multiple
clinic visits. John’s physician noticed the sudden
shift in motivation and capitalized on this and provided
assistance in recommending specific medical
intervention. Additionally, the physician provided
extra resources outside the clinic, in this
case a national hotline. If there are other resources
available to you, such as access to counselors
trained in behavioral smoking cessation interventions
or support groups in the local area, then integrating
these resources can help increase the
likelihood that the patient will succeed in ceasing
tobacco use. Finally, the physician made sure to
arrange for a follow-up with the patient to check
in about smoking. This allows the physician to
monitor this critical health behavior, and it can
provide the patient with a greater sense of support
through this very challenging experience.
Smoking cessation is a difficult process for both the patient and their healthcare providers.
However, brief interventions at each visit, and
providing assistance once the patient appears
motivated to quit, can greatly increase the chances
of improving the health of many patients.
References
- Fiore MC, Baker TB. Treating smokers in the health care setting.
NEJM 2011; 365: 1222-1231.
- Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and
dependence: 2008 update. Rockville, MD: Dept. of HHS, US
Pub Health Serv, 2008.
- Bath C. Patients with cancer need to know that it is never too
late to quit smoking. ASCO Post; Mar 15, 2013: 120-121.
- Ostroff J, Burkhalter J, Cinciripini P, et al. Randomized trial
of a presurgical, scheduled reduced smoking intervention for
patients newly diagnosed with cancer. Poster presented at 2013
APOS Annual Conf, Feb 15, 2013. As cited in Bales K. Tobacco
cessation needed in routine cancer care. ASCO Post, Mar 15,
2013: 35.
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Received: 1/14/2014
Accepted: 4/1/2014
Reviewers:Cynthia Jumper MD
Published electronically: 4/15/2014
Conflict of Interest Disclosures: None
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