EVIDENCE-BASED ANSWER
Quit date abstinence (strength of recommendation [SOR]: B, based on low-quality randomized controlled trial [RCT] of healthy subjects) and refraining from tobacco products within the first 2 weeks after an attempt (SOR: A, based on 2 RCTs) predict long-term abstinence from smoking. Inconsistent studies variously identify being married, a diagnosis of coronary artery disease (CAD) within the past 2 years, a higher education level, advanced age, and social status (such as being a homeowner) as factors correlated with successful smoking cessation (SOR: C, based on prospective cohort studies with conflicting results).
Smoking cessation rates increase in a dose-response relationship with minutes per counseling session, number of counseling sessions, and total minutes of counseling time (SOR: A, based on good-quality meta-analyses). Among counseling techniques, providing smokers with practical counseling (problem-solving skills), providing social support as part of treatment, helping smokers obtain social support outside of treatment, and use of aversive smoking interventions (eg, rapid smoking) seem to be efficacious (SOR: B, based on limited-quality meta-analyses).
CLINICAL COMMENTARY
Address a patient’s smoking in every encounter and at every opportunity
Stephen Elgert, MD
New Hampshire-Dartmouth Family Practice Residency, Concord, NH
The studies reviewed here do not show a stellar record of success in ridding patients of tobacco addiction. Few studies have success rates over the break-even point. Does this mean we should be nihilistic about this problem? Of course not!
I try to address a patient’s smoking in every encounter and at every opportunity. I ask them why they smoke and often get quizzical looks in return. I often ask them to do homework and write down the exact reason(s) they smoke each cigarette through the course of a day. Many times, one reason (such as stress) dominates the list. Others may have many reasons. Helping patients quit smoking is difficult unless we address the underlying reasons with creative alternatives and interventions.
Problem-solving with your patient can help. Suggesting alternative ways of dealing with stress can be enabling. Many of our patients are conscious of the relationship with weight gain and smoking, and give suggestions to counterbalance this notion.
Behavioral modification may help those resistant to change. Patients cannot help but wince as I describe the image of licking a dirty ashtray as they puff away. Smoking is a complex behavioral activity seldom cured by simple interventions, however. Tailoring efforts to meet our patients’ needs in a creative manner, tuned to their specific circumstances, is what we should aim to do.
Evidence summary
This answer focuses on the behavioral and sociodemographic factors involved in smoking cessation and does not review the pharmacologic approaches to a successful smoking cessation attempt.
In 1999, 41.3% of current smokers (95% confidence interval [CI], 39.8–42.8) reported quit attempts of at least 1 day during the preceding 12 months.1 In a 1994 survey of 2000 United Kingdom adults, 70% of smokers reported a desire to quit smoking, and 89% of smokers reported at least 1 quit attempt.2 Cochrane Library meta-analyses have found that brief advice from physicians (odds ratio [OR]=1.69; 95% CI, 1.45–1.98), individual counseling or group counseling (OR=1.55; 95% CI, 1.27–1.90), self-help materials (OR=1.23; 95% CI, 1.02–1.49), and nicotine replacement therapy (OR=1.71; 95% CI, 1.60–1.83) enhanced quit rates over a 6-month or greater period.3
However, relapse from smoking cessation is a significant problem. In the 1996 California Tobacco Survey of 4480 Californians, only 15.2% of those who used smoking cessation assistance (self-help, counseling, or nicotine replacement therapy), and 7.0% who used no assistance were abstinent from tobacco in 12 months.4
Smoking during the first 2 weeks of an attempt predicts decreased long-term cessation rates. In 2 independent randomized, double-blinded, placebo-controlled studies, 200 subjects were placed on various doses of nicotine replacement (study one: 22-mg nicotine patch for 8 weeks, study two: 22-mg patch for 4 weeks then 11 mg patch for 2 weeks). Of those who remained abstinent during the first 2 weeks while on a patch, 46.2% and 40.9% maintained abstinence at 6 months (OR=4.3 and 23.5, respectively) while abstinent subjects on placebo maintained abstinence at a rate of 43.8% and 30% (OR=9.7 and 18.9, respectively). Conversely, of those who were on a patch and smoked during the first 2 weeks of an attempt, 83.3% and 97.1% were smoking 6 months out while 92.6% and 97.8% of those in the placebo groups who smoked during the first 2 weeks were smoking at 6 months.5
In 2 randomized, non-placebo-controlled clinical trials of 200 subjects, 41.3% of smokers placed on nicotine replacement that were abstinent on their quit date and had a low tobacco dependence score (based on the Fagerström Test for Nicotine Dependence) were able to maintain abstinence at the 6-month mark (OR=4.1). Those who smoked on the quit date were 10 times less likely to have long-term success (OR=0.1).6