BOSTON — Physicians can go a long way toward helping their patients successfully quit smoking by thinking about tobacco dependence as a chronic disease, according to Dr. Donald J. Brideau Jr., a family physician in Alexandria, Va.
Tobacco dependence, just like diabetes or hypertension, is a chronic problem that requires follow-up and education to prevent relapse, so physicians can use the same types of strategies and patient education techniques that they use from other chronic illnesses, said Dr. Brideau, chief medical officer at Inova Mount Vernon Hospital in Alexandria.
Dr. Brideau offered this and other tips culled from the clinical practice guidelines on smoking cessation at the annual meeting of the American Academy of Family Physicians.
Another important way to increase quitting success is to offer every tobacco user some form of therapy, whether it's a pure behavioral approach or medication. This, however, requires physicians or their staffs to systematically identify every smoker or former smoker at every visit. It doesn't matter who does it or how it is done, but it should be done at every visit, he said. Practices can use stickers on charts or make smoking a fifth vital sign.
Once the smokers have been identified, it is important to assess their readiness to quit. The amount of time spent counseling them depends on where they are on the quitting spectrum. If patients say they are not ready to quit, keep the discussion brief. Let them know that you will be there when they are ready and that you will continue to ask them about it, Dr. Brideau said.
If, however, patients say they could be ready to quit in the next 30 days, they will need information on pharmacologic therapy and advice on other ways they can prepare for their quit date.
When it comes to actually quitting, the literature supports the use of counseling, pharmacologic treatments, and the combination of the two approaches, said Dr. Brideau, who disclosed a financial relationship with Pfizer and the Candela Corp.
In terms of counseling, the evidence shows that the duration and number of sessions is important to increasing success rates. Dr. Brideau tries to get his patients to commit to coming to four office visits over 3 or 4 months to discuss their progress.
Pharmacologic intervention should be a part of the approach for most patients. Clinical practice guidelines for smoking cessation recommend that all smokers be offered some form of pharmacologic intervention, unless there is a contraindication. Patients will have the greatest chance for success, though, if they receive a combination of medication and counseling. Practically, that could mean coupling medication with a 15-minute office visit that is devoted exclusively to a discussion about smoking cessation. Even that small effort could significantly increase success in quitting, Dr. Brideau said.
Another effective approach is to recommend telephone quit lines. Multiple randomized controlled trials support the use of these hotlines in increasing success rates. It's no surprise that the quit lines are successful, because they offer individualized counseling to patients, he said.
When patients are unwilling to quit, don't give up. Instead, consider using motivational interviewing techniques. When talking to a patient about quitting, for example, focus on their feelings and why they don't want to set a quit date. Try to figure out what rewards they get from smoking and what the roadblocks are to making a cessation attempt. Many patients will resist, so don't take it personally, and continue to repeat the smoking cessation message with each visit, Dr. Brideau advised.